NUTRITION SURVEYS DADAAB REFUGEE CAMPS Ifo-2, Hagadera ... · UNHCR Dadaab Nutrition Surveys,...

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NUTRITION SURVEYS

DADAAB REFUGEE CAMPS

Ifo-2, Hagadera, and Kambioos camps

Surveys conducted: September / October 2012

Report finalised: March 2013

UNHCR

IN COLLABORATION WITH

UCL, ENN

KRCS, IRC, GIZ, IMC, ADEO

WFP, UNICEF

NHCR Dadaa
b Nutrition Surveys, Sept-Oct 2012 of 128
http://www.giz.de/en/html/index.html

UNHCR Dadaab Nutrition Surveys, Sept-Oct 2012 of 128


TABLE OF CONTENTS

ACRONYMS AND ABBREVIATIONS......................................................................................................6

ACKNOWLEDGMENTS .........................................................................................................................12

EXECUTIVE SUMMARY ........................................................................................................................13

INTRODUCTION.....................................................................................................................................24

BACKGROUND ......................................................................................................................................24Food Security Situation................................................................................................................25Health Situation.............................................................................................................................25Nutrition Situation .........................................................................................................................26Rapid Nutrition Assessments Carried Out in 2012 ....................................................................27

SURVEY OBJECTIVES..........................................................................................................................29

METHODOLOGY....................................................................................................................................29Sample size....................................................................................................................................29Sampling procedure: selecting clusters .....................................................................................31Sampling procedure: selecting households and individuals ...................................................32Questionnaires ..............................................................................................................................32Measurement methods .................................................................................................................33Household-level indicators ..................................................................................................... 33Individual-level indicators....................................................................................................... 34Case definitions and calculations ...............................................................................................35Classification of public health problems and targets................................................................38Training, coordination and supervision......................................................................................39Data Collection using Android phones .......................................................................................40Data analysis .................................................................................................................................41

RESULTS FROM HAGADERA CAMP, DADAAB (OCT 2012) .............................................................42

RESULTS FROM IFO-2 CAMP, DADAAB (SEPT 2012).......................................................................61

RESULTS FROM KAMBIOOS CAMP, DADAAB (SEPT 2012) ............................................................77

LIMITATIONS .........................................................................................................................................95

DISCUSSION ..........................................................................................................................................96

CONCLUSION ......................................................................................................................................102

REFERENCES......................................................................................................................................103

Appendix 1 - Names of contributors .................................................................................................104Appendix 2 ...........................................................................................................................................106Appendix 3 ..........................................................................................................................................109Appendix 4 - Assignment of clusters ........................................................................................... 110Appendix 5 - Maps of Dadaab camps................................................................................................113Appendix 6 - Plan of Kambioos Block...............................................................................................116Appendix 7 - Survey questionnaires .................................................................................................117Appendix 8 - Local events calendar – children 0 – 59 months of age............................................127


ACRONYMS AND ABBREVIATIONS

ANC Ante Natal Care / ClinicADEO African Development and Emergency OrganizationBSFP Blanket Supplementary Feeding ProgramCDR Crude Death RateCI Confidence IntervalCHW Community Health WorkersCSB++ Corn-Soya Blend (Super cereal++)CTC Community Therapeutic CareDEFF Design effectENA Emergency Nutrition AssessmentENN Emergency Nutrition NetworkEPI Expanded Programme on ImmunizationEpi Info A software package for epidemiological investigationsFSNAU Food Security and Nutrition Analysis UnitGAM Global Acute MalnutritionGFD General Food DistributionGFR General Food RationGPS Global Positioning SystemHAZ Height-for-Age z-scoreHb HaemoglobinHH HouseholdHIS Health Information SystemIPs Implementing PartnersIYCF Infant and Young Child FeedingIMC International Medical CorpIRC International Rescue CommitteeKRCS Kenya Red Cross SocietyLNS Lipid-based Nutrient SupplementMAM Moderate Acute MalnutritionMCH Maternal and Child HeathMoH Ministry of HealthMSF Médecins sans FrontièresMUAC Middle Upper Arm circumferenceNCHS National Centre for Health StatisticsOTP Out-patient Therapeutic ProgrammePDM Post Distribution MonitoringPPS Probability Proportional to SizeProGres UNHCR registration database for refugeesRTI Respiratory Tract InfectionSAM Severe Acute MalnutritionSC Stabilization CentreSD Standard DeviationSFP Supplementary Feeding ProgrammeSMART ` Standardised Monitoring & Assessment of Relief & TransitionsTFP Therapeutic Feeding ProgrammeUCL University College of LondonU5 Children under 5 years oldU5DR Under-5 Death RateUNHCR United Nations High Commissioner for RefugeesUNICEF United Nations Children’s FundsWASH Water, Sanitation, and HygieneWAZ Weight-for-Age z-scoreWHZ Weight-for-Height z-scoreWFP World Food ProgrammeWHO World Health Organization


FIGURES

Figure 1 Under-five proportional morbidity from October 2011 to September 2012 - cumulative(UNHCR Health Information System).............................................................................................. 27Figure 2 Admissions to community therapeutic care August 2011 to August 2012 (HealthInformation System) ........................................................................................................................ 28Figure 3 Admissions to Targeted SFP August 2011 to August 2012 (Health Information System) 28Figure 4 Trends in GAM and SAM since 2009 - Hagadera camp, Dadaab (Oct 2012).................. 43Figure 5 Trends in the prevalence of wasting by age in children 6-59 months - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 44Figure 6 Distribution of weight-for-height z-scores (based on WHO Growth Standards; thereference population is shown in green) of survey population compared to reference population-Hagadera camp, Dadaab (Oct 2012). ............................................................................................. 45Figure 8 Nutrition survey results (anaemia in children 6-59 months) since 2009 - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 47Figure 9 Anaemia in children 6-23 months, since 2009-Hagadera camp, Dadaab (Oct 2012) ...... 48Figure 10 Nutrition survey results: vitamin A supplementation within past 6 months with card) since2010 -Hagadera camp, Dadaab (Oct 2012).................................................................................... 50Figure 11 Measles vaccination coverage trends since August 2010 – Hagadera camp, Dadaab(Oct 2012)........................................................................................................................................ 51Figure 12 Nutrition survey results (deworming for children aged 24-59 months within past 6months) since 2010 – Hagadera camp, Dadaab (Oct 2012) .......................................................... 51Figure 13 Nutrition survey results (key IYCF indicators) since 2009 - Hagadera camp, Dadaab (Oct2012) ............................................................................................................................................... 53Figure 14 Nutrition survey results (anaemia) since 2009-Hagadera camp, Dadaab (Oct 2012) .... 55Figure 15 Trends in coverage of ANC programmes, Hagadera (2012) .......................................... 56Figure 16 Household size – Hagadera Camp, Dadaab (Oct 2012) ................................................ 57Figure 17 Main reason given by households (n=222) for why the general food ration did not lastuntil the next distribution - Hagadera camp, Dadaab (Oct 2012).................................................... 58Figure 18 Coping strategies used by households (n=222) to fill the food gap when general foodration runs out - Hagadera camp, Dadaab (Oct 2012).................................................................... 58Figure 19 Most common items bought when general ration is sold or exchanged - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 59Figure 20 Trends in the prevalence of wasting by age in children 6-59 months - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 63Figure 21 Distribution of weight-for-height z-scores (based on WHO Growth Standards; thereference population is shown in green) of survey population compared to reference population -Ifo-2 camp, Dadaab (Sept 2012) ..................................................................................................... 63Figure 22 Trends in the prevalence of stunting by age in children 6-59 months - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 64Figure 23 Household size – Ifo-2 Camp, Dadaab (Sept 2012) ....................................................... 73Figure 24 Main reason given by each household for why the general good ration did not last untilthe next distribution - Ifo-2 camp, Dadaab (Sept 2012) .................................................................. 74Figure 25 Main coping strategies used to fill the food gap when general food ration runs out - Ifo-2camp, Dadaab (Sept 2012) ............................................................................................................. 75Figure 26 Most common items bought when general ration is sold or exchanged - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 76Figure 27 Trends in the prevalence of wasting by age in children 6-59 months - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 79Figure 28 Distribution of weight-for-height z-scores (based on WHO Growth Standards; thereference population is shown in green) of survey population compared to reference population -Kambioos camp, Dadaab (Sept 2012) ............................................................................................ 80Figure 29 Prevalence of stunting (including severity) by age in children 6-59 months - Kambiooscamp, Dadaab (Sept 2012) ............................................................................................................. 81Figure 30 Household size – Kambioos Camp, Dadaab (Sept 2012) .............................................. 90Figure 31 Main reason given by each household for why general good ration did not last 15 days -Kambioos camp, Dadaab (Sept 2012) ............................................................................................ 91Figure 32 Coping strategies used to fill the food gap when general food ration runs out - Kambiooscamp, Dadaab (Sept 2012) ............................................................................................................. 92Figure 33 Most common items bought when general ration is sold or exchanged - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 93


TABLES

Table 1 Contents of the general food ration – Dadaab refugee camps .......................................... 25Table 2 Sample size justification for household-level indicators..................................................... 30Table 3 Sample size justification for individual-level indicators (all camps).................................... 30Table 4 Sample size justification and rationale for acute malnutrition in children 6-59 months ..... 31Table 5 Definitions of acute malnutrition using weight-for-height and/or oedema in children 6-59months............................................................................................................................................. 36Table 6 Definitions of stunting using height-for-age in children 6–59 months ................................ 36Table 7 Definitions of underweight using weight-for-age in children 6–59 months......................... 36Table 8 Classification of acute malnutrition based on MUAC in children 6-59 months (WHO) ...... 37Table 9 Definition of anaemia (WHO 2000) .................................................................................... 38Table 10 Mortality benchmarks for defining crisis situations (NICS, 2010)..................................... 38Table 11 Classification of public health significance for children under 5 years of age (WHO 1995,2000) ............................................................................................................................................... 38Table 12 Classification of public health significance (WHO 2000).................................................. 39Table 13 UNHCR WASH Programme Standards ........................................................................... 39Table 14 Target sample size and actual number captured during the survey - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 42Table 15 Demographic information - Hagadera camp, Dadaab (Oct 2012) ................................... 42Table 16 Distribution of age and sex of sample - Hagadera camp, Dadaab (Oct 2012) ................ 43Table 17 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)and by sex - Hagadera camp, Dadaab (Oct 2012) ......................................................................... 43Table 18 Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/oroedema -Hagadera camp, Dadaab (Oct 2012)............................................................................... 44Table 19 Distribution of severe acute malnutrition and oedema based on weight-for-height z-scores -Hagadera camp, Dadaab (Oct 2012) ................................................................................. 44Table 20 Prevalence of stunting based on height-for-age z-scores and by sex - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 45Table 21 Prevalence of stunting by age based on height-for-age z-scores - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 45Table 22 Prevalence of underweight based on weight-for-age z-scores by sex-Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 46Table 23 Mean z-scores, Design Effects and excluded subjects - Hagadera camp, Dadaab (Oct2012) ............................................................................................................................................... 46Table 24 Prevalence of malnutrition based on MUAC (N=600) - Hagadera camp, Dadaab (Oct2012) ............................................................................................................................................... 46Table 25 Estimated number of malnourished children aged 6-59 months eligible to be enrolled inacute malnutrition treatment feeding programmes (case load) at the time of the survey (based onall admission criteria) - Hagadera camp, Dadaab (Oct 2012) ......................................................... 47Table 26 Prevalence of anaemia and haemoglobin concentration in children 6-59 months of age -Hagadera camp, Dadaab (Oct 2012) (n = 600)............................................................................... 47Table 27 Prevalence of anaemia by age - Hagadera camp, Dadaab (Oct 2012) ........................... 48Table 28 Acute malnutrition treatment programme coverage based on all admission criteria(weight-for-height, MUAC, oedema) - Hagadera camp, Dadaab (Oct 2012).................................. 49Table 29 Acute malnutrition treatment programme coverage based on MUAC and oedemaadmission criteria only - Hagadera camp, Dadaab (Oct 2012) ....................................................... 49Table 30 CSB++ Distribution (BSFP programme) for children aged 6-23 months - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 49Table 31 Measles vaccination coverage for children aged 9-59 months (n=572) - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 49Table 32 PENTA vaccination coverage for children aged 6-59 months (n= 600) - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 50Table 33 Vitamin A supplementation for children aged 6-59 months ............................................. 50Table 34 Deworming for children aged 24-59 months within past 6 months (n = 395) - Hagaderacamp, Dadaab (Oct 2011) ............................................................................................................... 51Table 35 Prevalence of reported diarrhoea in the two weeks prior to the interview - Hagaderacamp, Dadaab (Oct 2012) ............................................................................................................... 52Table 36 Feeding during diarrhoea episodes - Hagadera camp, Dadaab (Oct 2012).................... 52Table 37 Demographic information - Hagadera camp, Dadaab (Oct 2012) ................................... 52Table 38 Prevalence of Infant and Young Child Feeding Practices indicators - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 53


Table 39 Demographic profile of survey sample - Hagadera camp, Dadaab (Oct 2012) ............... 53Table 40 Prevalence of anaemia in non-pregnant women of reproductive age (15-49 years) -Hagadera camp, Dadaab (Oct 2012) (n = 281)............................................................................... 54Table 41 ANC enrolment and iron-folic acid pills coverage among pregnant women (15-49 years) -Hagadera camp, Dadaab (Oct 2012) .............................................................................................. 55Table 42 Post-natal vitamin A supplementation among women (15-49 years) - Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 55Table 43 Target sample size and actual number captured during the survey-Hagadera camp,Dadaab (Oct 2012) .......................................................................................................................... 56Table 44 Demographic information - Hagadera camp, Dadaab (Oct 2012) ................................... 56Table 45 Demographic information - Hagadera camp, Dadaab (Oct 2012) ................................... 57Table 46 Ration card coverage and duration of general food ration - Hagadera camp, Dadaab (Oct2012) ............................................................................................................................................... 57Table 47 Duration that GFR lasts in Households - Hagadera Camp, Dadaab (Oct 2012) ............. 57Table 48 Sale or exchange of food from general ration - Hagadera camp, Dadaab (Oct 2012) ... 59Table 49 Ownership of adequate water containers - Hagadera camp, Dadaab (Oct 2012)........... 59Table 50 Proportion of HH using an improved drinking water source – Hagadera camp, Dadaab(Oct 2012)........................................................................................................................................ 60Table 51 Satisfaction with water supply - Hagadera camp, Dadaab (Oct 2012) ............................ 60Table 52 Soap distribution - Hagadera camp, Dadaab (Oct 2012)................................................. 60Table 53 Safe Excreta disposal - Hagadera camp, Dadaab (Oct 2012)......................................... 60Table 54 Sharing of Toilet Facilities - Hagadera camp, Dadaab (Oct 2012) .................................. 60Table 55 Target sample size and actual number sampled during the survey - Ifo-2 camp, Dadaab(Sept 2012)...................................................................................................................................... 61Table 56 Demographic information - Ifo-2 camp, Dadaab (Sept 2012) .......................................... 61Table 57 Distribution of age and sex of sample - Ifo-2 camp, Dadaab (Sept 2012) ....................... 62Table 58 Prevalence of acute malnutrition based on weight-for-height z-scores ........................... 62Table 59 Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/oroedema - Ifo-2 camp, Dadaab (Sept 2012)..................................................................................... 62Table 60 Distribution of severe acute malnutrition and oedema based on weight-for-height z-scores - Ifo-2 camp, Dadaab (Sept 2012) ....................................................................................... 63Table 61 Prevalence of stunting based on height-for-age z-scores and by sex - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 64Table 62 Prevalence of stunting by age based on height-for-age z-scores - Ifo-2 camp, Dadaab(Sept 2012)...................................................................................................................................... 64Table 63 Prevalence of underweight based on weight-for-age z-scores by sex - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 65Table 64 Mean z-scores, Design Effects and excluded subjects - Ifo-2 camp, Dadaab (Sept 2012)......................................................................................................................................................... 65Table 65 Prevalence of malnutrition based on MUAC (N=630) - Ifo-2 camp, Dadaab (Sept 2012)66Table 66 Estimated number of malnourished children aged 6-59 months eligible to be enrolled in aselective feeding programme at the time of the survey (based on all admission criteria) - Ifo-2camp, Dadaab (Sept 2012) ............................................................................................................. 66Table 67 Prevalence of anaemia and haemoglobin concentration in children 6-59 months of age -Ifo-2 camp, Dadaab (Sept 2012) (n = 629) ..................................................................................... 66Table 68 Prevalence of anaemia by age - Ifo-2 camp, Dadaab (Sept 2012).................................. 67Table 69 Nutrition treatment programme coverage based on all admission criteria (weight-for-height, MUAC, oedema) - Ifo-2 camp, Dadaab (Sept 2012) ........................................................... 67Table 70 Nutrition treatment programme coverage based on MUAC and oedema only - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 67Table 71 Measles vaccination coverage for children aged 9-59 months (n=596) - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 68Table 72 PENTA vaccination coverage for children aged 6-59 months (n=630) - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 68Table 73 Vitamin A supplementation for children aged 6-59 months within past 6 months (n=630) -Ifo-2 camp, Dadaab (Sept 2012) ..................................................................................................... 68Table 74 Deworming for children aged 24-59 months within past 6 months (n=447) - Ifo-2 camp,Dadaab (Sept 2011) ........................................................................................................................ 68Table 75 CSB++ Distribution (BSFP programme) for children aged 6-23 months - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 69Table 76 Prevalence of reported diarrhoea in the two weeks prior to the interview - Ifo-2 camp,Dadaab (Sept 2012) ........................................................................................................................ 69


Table 77 Feeding during diarrhoea episodes - Ifo-2 camp, Dadaab (Sept 2012)........................... 69Table 78 Demographic information - Ifo-2 camp, Dadaab (Sept 2012) .......................................... 69Table 79 Prevalence of Infant and Young Child Feeding Practices indicators - Ifo-2 camp, Dadaab(Sept 2012)...................................................................................................................................... 70Table 80 Demographic information - Ifo-2 camp, Dadaab (Sept 2012) .......................................... 70Table 81 Prevalence of anaemia and haemoglobin concentration in non-pregnant women ofreproductive age (15-49 years) - Ifo-2 camp, Dadaab (Sept 2012) (n = 261)................................. 71Table 82 ANC enrolment and iron-folic acid pills coverage among pregnant women (15-49 years) -Ifo-2 camp, Dadaab (Sept 2012) ..................................................................................................... 71Table 83 Post-natal vitamin A supplementation among women (15-49 years) - Ifo-2 camp, Dadaab(Sept 2012)...................................................................................................................................... 71Table 84 Target sample size and actual number captured for HH Questionnaire during the survey -Ifo-2 camp, Dadaab (Sept 2012) ..................................................................................................... 72Table 85 Demographic information - Ifo-2 camp, Dadaab (Sept 2012) .......................................... 72Table 86 Ownership of adequate water containers - Ifo-2 camp, Dadaab (Sept 2012).................. 72Table 87 Proportion of HH using an improved drinking water source - Ifo-2 camp, Dadaab (Sept2012) ............................................................................................................................................... 72Table 88 Satisfaction with water supply - Ifo-2 camp, Dadaab (Sept 2012) ................................... 72Table 89 Soap distribution - Ifo-2 camp, Dadaab (Sept 2012)........................................................ 73Table 90 Safe Excreta disposal - Ifo-2 camp, Dadaab (Sept 2012)................................................ 73Table 92 Demographic information - Ifo-2 camp, Dadaab (Sept 2012) .......................................... 73Table 93 Ration card coverage and duration of general food ration - Ifo-2 camp, Dadaab (Sept2012) ............................................................................................................................................... 74Table 94 Duration of 15 days cycle that the General Food Ration lasted – Ifo-2 camp, Dadaab(2012) .............................................................................................................................................. 74Table 95 Sell or exchange of food from the general ration - Ifo-2 camp, Dadaab (Sept 2012) ...... 75Table 96 Target sample size and actual number captured during the survey - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 77Table 97 Demographic information - Kambioos camp, Dadaab (Sept 2012) ................................. 77Table 98 Distribution of age and sex of sample - Kambioos camp, Dadaab (Sept 2012) .............. 78Table 99 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema)and by sex - Kambioos camp, Dadaab (Sept 2012) ....................................................................... 78Table 100 Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/oroedema - Kambioos camp, Dadaab (Sept 2012)............................................................................ 79Table 101 Distribution of severe acute malnutrition and oedema based on weight-for-height z-scores - Kambioos camp, Dadaab (Sept 2012) .............................................................................. 79Table 102 Prevalence of stunting based on height-for-age z-scores and by sex - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 80Table 103 Prevalence of stunting by age based on height-for-age z-scores - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 81Table 104 Prevalence of underweight based on weight-for-age z-scores by sex - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 81Table 105 Mean z-scores, Design Effects and excluded subjects - Kambioos camp, Dadaab (Sept2012) ............................................................................................................................................... 82Table 106 Prevalence of malnutrition based on MUAC (N=599) - Kambioos camp, Dadaab (Sept2012) ............................................................................................................................................... 82Table 107 Estimated number of malnourished children aged 6-59 months eligible to be enrolled ina selective feeding programme at the time of the survey (based on all admission criteria) -Kambioos camp, Dadaab (Sept 2012) ............................................................................................ 82Table 108 Prevalence of anaemia and haemoglobin concentration in children 6-59 months of age -Kambioos camp, Dadaab (Sept 2012) (n = 599) ............................................................................ 83Table 109 Prevalence of anaemia by age - Kambioos camp, Dadaab (Sept 2012)....................... 83Table 110 Acute malnutrition treatment programme coverage based on all admission criteria(weight-for-height, MUAC, oedema) – Kambioos camp, Dadaab (Sept 2012) ............................... 84Table 111 Acute malnutrition treatment programme coverage based on MUAC and oedema only -Kambioos camp, Dadaab (Sept 2012) ............................................................................................ 84Table 112 CSB++ Distribution (BSFP programme) for children aged 6-23 months- Kambiooscamp, Dadaab (Sept 2012) ............................................................................................................. 84Table 113 Measles vaccination coverage for children aged 9-59 months (n=584) – Kambiooscamp, Dadaab (Sept 2012) ............................................................................................................. 85Table 114 PENTA vaccination coverage for children aged 6-59 months (n=599) - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 85


Table 115 Vitamin A supplementation for children aged 6-59 months within past 6 months (n=599)– Kambioos camp, Dadaab (Sept 2012) ......................................................................................... 85Table 116 Deworming for children aged 24-59 months within past 6 months (n=599) – Kambiooscamp, Dadaab (Sept 2012) ............................................................................................................. 85Table 117 Prevalence of reported diarrhoea in the two weeks prior to the interview - Kambiooscamp, Dadaab (Sept 2012) ............................................................................................................. 86Table 118 Feeding during diarrhoea episodes - Kambioos camp, Dadaab (Sept 2012)................ 86Table 119 Demographic information - Kambioos camp, Dadaab (Sept 2012) ............................... 86Table 120 Prevalence of Infant and Young Child Feeding Practices indicators - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 87Table 121 Demographic information - Kambioos camp, Dadaab (Sept 2012) ............................... 87Table 122 Prevalence of anaemia and haemoglobin concentration in non-pregnant women ofreproductive age (15-49 years) - Kambioos camp, Dadaab (Sept 2012) (n = 256)........................ 88Table 123 ANC enrolment and iron-folic acid pills coverage among pregnant women (15-49 years)- Kambioos camp, Dadaab (Sept 2012) .......................................................................................... 88Table 124 Post-natal vitamin A supplementation among women (15-49 years) - Kambioos camp,Dadaab (Sept 2012) ........................................................................................................................ 88Table 125 Target sample size and actual number captured for HH Questionnaire during the survey-Kambioos camp, Dadaab (Sept 2012) ........................................................................................... 89Table 126 Demographic information - Kambioos camp, Dadaab (Sept 2012) ............................... 89Table 127 Ownership of adequate water containers - Kambioos camp, Dadaab (Sept 2012)....... 89Table 128 Main source of drinking water for HH - Kambioos camp, Dadaab (Sept 2012) ............. 89Table 129 Satisfaction with water supply - Kambioos camp, Dadaab (Sept 2012) ........................ 89Table 130 Soap distribution - Kambioos camp, Dadaab (Sept 2012)............................................. 90Table 131 Safe Excreta disposal - Kambioos camp, Dadaab (Sept 2012)..................................... 90Table 133 Demographic information - Kambioos camp, Dadaab (Sept 2012) ............................... 90Table 134 Ration card coverage and duration of general food ration - Kambioos camp, Dadaab(Sept 2012)...................................................................................................................................... 91Table 135 Duration that GFR lasts – Kambioos camp, Dadaab (Sept 2012) ................................. 91Table 136 Selling or exchange of food from the general ration - Kambioos camp, Dadaab (Sept2012) ............................................................................................................................................... 92Table 137 Demographic and retrospective mortality - Kambioos, Dadaab (Sept 2012)................. 93Table 138 Summary table of mean z-score, design effect, and excluded subjects for the weight-for-height index using both reference populations - Ifo-2 camp (Oct 2012).................................. 109Table 139 Summary table of mean z-score, design effect and excluded subjects for the weight-for-height index using both reference populations - Hagadera camp (Sept 2012)............................. 109Table 140 Summary table of mean z-score, design effect and excluded subjects for the weight-for-height index using both reference populations - Kambioos camp (Sept 2012) ............................ 109


ACKNOWLEDGMENTS

UNHCR commissioned and coordinated the surveys with technical support from UCL,ENN and CartONG. The commitment and support provided to the Dadaab-basedmanagement team (Mary Koech, Sandra Sudhoff, Andrew Seal, Jo McElhinney) for sucha large undertaking was much appreciated and is gratefully acknowledged - a number ofindispensable persons stepped up to the challenge. Contributions from all stakeholdersallowed these surveys to be conducted under difficult and insecure circumstances.

We would like to acknowledge all agencies involved in planning and conducting thesurveys. Thanks go to KRCS, IRC, IMC, GIZ, MSF-CH and ADEO for providing staff forthe entire duration of the exercise. Thanks to ADEO staff, and in particular MaryOrwenyo, for providing Logistics and Procurement for the survey.

Thanks to Edna Moturi, Geoffrey Luttah from the UNHCR Dadaab Sub-Office, Dr JohnBurton from the Kenya Branch Office, and Allison Oman and Ismail Arte Rage Kassimfrom the Regional Support Office, for hosting and supporting the UCL and CartONGsurvey team.

Thanks to UNICEF for contributing anthropometric equipment for the survey. Thanks forUNICEF and WFP for their support with team supervision during training and datacollection, especially Frances Kidake.

The UNHCR IT support and ProGres staff in Dadaab are acknowledged for their greatsupport throughout the duration of the training and data collection.

Thanks also to all drivers for their assistance.

A list of names of all people involved in the survey is provided in Appendix 1.

And finally, thanks go to the Dadaab refugee population for their participation andinvolvement.


EXECUTIVE SUMMARY

UNHCR, with technical support from UCL / ENN, and in collaboration with WFP, UNICEF,and its implementing partners, KRCS, IMC, GIZ, IRC, MSF-CH, and ADEO, carried out anutrition survey in each of the five camps of Dadaab Complex: Dagahaley, Hagadera, Ifo,Ifo-2 and Kambioos. These five surveys took place between 19th September and 8th

October 2012, with the overall aim of determining the extent and severity of malnutritionof children aged 6-59 months and to monitor selected indicators of programmeperformance, in order to deliver appropriate recommendations. Only three of the fivesurvey results are reported here due to concerns regarding the quality of data collectedfrom two camps; Dagahaley and Ifo.

The survey objectives were as follows:

Primary Objectives

1. To determine the prevalence of acute malnutrition among children 6-59 months.2. To determine the prevalence of stunting among children 6-59 months.3. To investigate IYCF practices among children 0-23 months.4. To assess the prevalence of anaemia among children 6-59 months.5. To assess the prevalence of anaemia among non-pregnant women of reproductive

age (15-49 years).6. To assess the two-week period prevalence of diarrhoea among children (0-59

months).7. To determine the coverage of measles vaccination among children (9-59 months).8. To determine the coverage of de-worming in children (24-59 months) and vitamin A

supplementation among children (6-59 months) in the last six months.9. To assess the coverage of blanket supplementary feeding programmes for children

6-23 months.10. To determine the coverage of ration cards and the duration the general food ration

lasts for recipient households.11. To determine which coping strategies are used by households to address shortfalls in

the general ration.12. To determine the population’s access to improved water, sanitation and hygiene

facilities.13. To assess crude and under-five death rates in the camps in the last three months in

Kambioos.14. To establish recommendations on actions to be taken to address the situation.

Secondary Objectives:

15. To assess the coverage of targeted selective feeding programmes for children 6-59months.

16. To determine the coverage of iron and folate supplementation in pregnant women.


Summary of results

Surveyed area

CampsClassification of publichealth significance ortarget (where applicable)

Hagadera(excluding outskirts)

Ifo-2(East & West)

Kambioos

Date of survey Oct 3rd – 8th Sept 19th – 24th Sept 26th – 1st

CHILDREN (6-59 months)

Planned sample size 600 600 600

Number of children surveyed 600 630 599

Acute Malnutrition(WHO 2006 Growth Standards)

% (95% CI) % (95% CI) % (95% CI)

Valid measurements available 594 622 594

Global Acute Malnutrition (GAM)10.3

(8.0 – 13.0)

15.0

(12.3 – 18.0)

17.2

(14.4 – 20.3)Critical if ≥ 15%

Moderate Acute Malnutrition (MAM)7.1

(5.2 – 9.6)

9.8

(7.8 – 12.2)

10.8

(8.2 – 14.0)

Severe Acute Malnutrition (SAM)3.2

(1.9 – 5.2)

5.1

(3.7 – 7.1)

6.4

(4.6 – 8.9)

Oedema 0.5 (n=3) 0.8 (n=5) 0.7 (n=4)

Stunting (chronic malnutrition)(WHO 2006 Growth Standards)

Total stunting (<2 z-scores)25.7%

(20.4 – 31.8)41.7%

(37.3 – 46.3)28.3%

(23.1 – 34.3)Critical if ≥ 40%

Moderate stunting (>=-3z scores and<-2z scores

18.4%(14.4 – 23.3)

22.8%(19.9 – 25.9)

18.5%(14.7 – 23.0)


Surveyed area



Ifo-2(East & West)

Kambioos


Severe stunting (<-3 z-scores)7.3%

(5.2 – 10.1)18.9%

(15.3 – 23.2)9.8%

(7.4 – 13.1)

Anaemia (6-59 months) % (95% CI) % (95% CI) % (95% CI)

Valid measurements 600 629 599

Total Anaemia (Hb <11 g/dl)44.5%

(39.2 50.0)

45.5%

(40.9 - 50.1)

50.8%

(45.3 - 56.2)High if ≥ 40%

Mild Anaemia23.0%

(19.4 – 26.6)

28.8%

(25.5 – 32.0)

29.4%

(25.4 – 33.4)

Moderate Anaemia20.8%

(16.8 – 24.8)

16.4%

(13.2 – 19.5)

21.0%

(17.0 – 25.0)

Severe Anaemia0.7%

(0.0 – 1.3)

0.3%

(0.0 – 0.8)

0.3%

(0.0 – 0.8)

Programme Coverage % (95% CI) % (95% CI) % (95% CI)

OTP(based on all admission criteria: WHZ,oedema and MUAC)

N= 1/19

5.3%

(0.7 – 31.4%)

N= 18/39

46.2%

(32.4 – 60.0)

N= 7/43

16.3%

(5.6 – 38.7)

Target >= 90%

OTP(based on MUAC and oedemaadmission criteria only)

N= 0/4

0.0%

-

N= 13/21

61.9%

(36.0 – 82.4)

N= 6/17

35.3%

(10.3 – 70.2)

TSFP (based on all admission criteria:WHZ and MUAC)

N= 5/51

9.8%

(2.8 – 29.1)

N=13/76

17.1%

(9.7 – 28.4)

N= 12/76

15.8%

(9.4 – 25.3)

Target >= 90%


Surveyed area



Ifo-2(East & West)

Kambioos


TSFP(based on MUAC admission criteriaonly)

N= 6/23

26.1%

(8.5 – 57.1)

N= 13/36

36.1%

(20.9 – 54.7)

N= 13/39

33.3%

(20.5 – 49.2)

BSFP - Currently receiving CSB++ *1

(6-23 months)

N= 13/204

6.4%

(2.4 – 10.3)

N= 34/177

19.2%

(11.1 – 27.3)

N= 19/205

9.3%

(2.9 – 15.6)

Measles Vaccination with card

(9-59 months)

N= 291/572

50.9%

(36.7 – 65.0)

N=133/596

22.3%

(16.3 - 29.8)

N= 61/584

10.4%

(3.4 – 17.4)

Target >= 95%

Measles Vaccination with card orrecall (9-59 months)

N= 560/572

97.9%

(96.0 – 99.8)

N= 497/596

83.4%

(70.1 – 91.5)

N= 564/584

96.6%

(93.9 – 99.2)

Vitamin A Supplementation coveragewith card, within past 6 months

(6-59 months)

N= 242/600

40.3%

(25.4 – 55.3)

N=146/630

23.2%

(15.9 – 32.9)

N= 35/599

5.8%

(2.9 – 8.7)

Target >= 90%

Vitamin A supplementation coveragewith card or recall, within past 6months (6-59 months)

N= 578/600

96.3%

(91.8 - 100.0)

N=617/630

97.9%

(95.1 – 99.1)

N= 569/599

94.8%

(90.9 – 98.8)

Deworming coverage by recall, withinpast 6 months

(24-59 months)

N= 379 / 395

95.9%

(91.1 – 100.0)

N= 301/447

67.3%

(52.6 – 79.3)

N= 502/599

83.8%

(77.7 – 89.6)

1 *The low coverage of the BSFP was confirmed by also looking at data on the proportion of children (6-23 months) who had received porridge made from CSB+or CSB++ in the last 24 hours. While these proportions are, in general, a little higher (10 – 49%) consumption of either type of CSB was low in this age group.


Surveyed area



Ifo-2(East & West)

Kambioos


Morbidity (children 6 – 59 months)

Diarrhoea in past 2 weeks

N= 5/599

0.8%

(0.1 – 1.5)

N= 195/630

31.0%

(22.3 – 39.6)

N= 75/599

12.5%

(7.8 – 17.3)

Demographics (children 6 – 59 months)

Mean Age (months)31.9

(31.1 – 32.8)

33.6

(32.3 – 34.9)

32.6

(31.6 – 33.7)

Date of Arrival in Dadaab:Before Oct 2011

98.7

(97.5 -99.9)

98.3%

(96.2 – 100.0)

95.0%

(88.7 – 100.0)

October – December 20110.3%

(0.0 – 0.8)

0.5%

(0.0 – 1.5)

1.2%

(0.0 – 3.0)

January – March 2012 0.0%0.5%

(0.0 – 1.5)

0.7%

(0.0 – 1.7)

April – June 20120.7%

(0.0 – 1.6)

0.8%

(0.0 – 2.4)

3.0%

(0.0 – 7.8)

July – Sept 20120.3%

(0.0 – 1.0)0.0%

0.2%

(0.0 – 0.5)

Ethnic Group:Somali

77.0%

(64.8 – 89.2)

87.8%

(81.2 – 94.4)

93.3%

(89.0 – 97.8)

Somali Bantu23.0%

(10.8 – 35.2)

12.2%

(5.6 – 18.8)

6.7%

(2.2 – 11.1)

Other 0.0% 0.0% 0.0%


Surveyed area



Ifo-2(East & West)

Kambioos


INFANTS AND YOUNG CHILDREN 0-23 MONTHS

Anaemia in children aged 6 – 23 months


(55.1 – 71.7)63.4%

(57.1 – 69.7)66.5%

(58.3 – 74.8)

Infant and Young Children Feeding Practices (IYCF)

Children ever breastfed93.4%

(89.0 – 97.8)

98.3%

(96.7 – 100.0)

97.2%

(95.0 – 99.5)

Timely initiation of breastfeeding96.0%

(91.9 – 100.0)

68.1%

(53.1 – 83.1)

87.6%

(78.6 – 96.6)

Exclusive breastfeeding under 6months

83.0%

(73.4 – 92.6)

72.7%

(62.2 – 83.1)

84.3%

(77.1 - 91.3)

Continued breastfeeding at 1 year63.4%

(45.3 – 81.5)

78.4%

(66.4 – 90.5)

57.1%

(40.2 – 74.0)

Introduction of solid, semi-solid orsoft foods

66.7%

(45.7 – 87.6)

50.0%

(30.6 – 69.4)

20.0%

(0.0 – 46.1)

Children bottle fed3.1%

(0.2 – 6.0)

3.3%

(1.1 – 5.6)

4.3%

(1.7 – 6.9)

Children given infant formula1.9%

(0.0 – 3.8)

1.0%

(0.0 – 2.2)

6.2%

(1.0 – 11.4)

Reported prevalence of diarrhoea4.7%

(2.0 – 7.3)

16.7%

(10.2 – 23.1)

10.8%

(5.7 – 15.9)

Continued feeding during diarrhoea46.7%

(7.2 – 86.2)

34.0%

(19.8 – 51.9)

0.0%

-


Surveyed area



Ifo-2(East & West)

Kambioos


WOMEN 15-49 YEARS

Anaemia (non-pregnant women)


(30.9 – 46.7)

33.3%

(25.4 – 41.3)

32.0%

(23.7 – 40.3)

Mild (Hb 11-11.9)18.1%

(12.9 – 23.4)

19.9%

(14.8 – 25.0)

12.5

(8.5 – 16.5)

Moderate (Hb 8-10.9)19.6%

(12.9 – 26.2)

12.6%

(7.5 – 17.8)

19.1%

(11.4 – 26.8)

Severe (Hb<8)1.1%

(0.0 – 2.3)

0.8%

(0.0 – 1.8)

0.4%

(0.0 – 1.2)

Programme coverage, pregnant and lactating

Pregnant women currently enrolledin ANC with card

96.0%

(87.5 – 100.0)

72.6%

(59.3 – 87.9)

96.6%

(91.3 – 100.0)

Pregnant women currently enrolledin ANC with card or recall

100.0%

-

75.0%

(61.0 – 89.0)

96.6%

(91.3 – 100.0)

Pregnant women currently receivingiron-folic acid pills

96.0%

(87.5 – 100.0)

70.8%

(56.7 – 84.9)

86.2%

(72.4 – 100.0)

Post-natal women who receivedvitamin A supplementation sincedelivery with card

45.8%

(27.3 – 64.3)

39.5%

(21.0 – 56.1)

48.5%

(30.8 – 66.2)


Surveyed area



Ifo-2(East & West)

Kambioos


Post-natal women who receivedvitamin A supplementation sincedelivery with card or recall

93.1%

(87.4 – 98.7)

84.9%

(74.2 – 95.6)

94.1%

(88.3 – 99.9)

HOUSEHOLD WATER, SANITATION, AND HYGIENE

Soap distribution % (95% CI)

Proportion of HH that received soapduring last two distribution cycles

98.6%

(96.8 – 100.0)

90.1%

(85.2 – 95.0)

98.8%

(97.6 – 100.0)

Target: >90% are providedwith >250 g per person permonth

Water quality

Proportion of HH that report havingenough water containers to collectwater

73.3%

(62.8 – 87.7)

3.7%

(0.5 – 7.0)

22.5%

(13.3 – 31.7)

Use Public Tap or Standpipe as mainsource of drinking water

99.7%

(99.2 – 100.0)

100.0%

-

96.8%

(90.3 – 100.0)

Proportion of households that saythey are satisfied with the drinkingwater supply

85.2%

(76.6 – 93.8)

84.8%

(74.0 – 95.5)

98.9%

(97.0 – 100.0)

Safe excreta disposal

Proportion of HH using an improvedtoilet (improved toilet facility, notshared)

36.6%

(27.4 – 48.4)

51.3%

(36.5 – 66.2)4.1%

(1.7 – 6.4%)

Proportion of HH using an improvedtoilet

17.3%

(10.3 – 24.4)

7.0%

(2.5 – 11.4)27.4%

(18.5 – 36.4)


Surveyed area



Ifo-2(East & West)

Kambioos


Proportion of HH using a communaltoilet

14.5%

(7.4 – 21.6)

30.0%

(17.0 – 43.0)64.9%

(54.3 – 75.4)

Proportion of HH using anunimproved toilet

31.0%

(18.7 – 44.4)

11.8%

(4.4 – 19.1)3.4%

(0.1 – 7.1)

HOUSEHOLD FOOD SECURITY

Proportion of HH with a ration card% (95% CI)

99.4%

(98.7 – 100.0)

100.0%

-

98.2%

(94.6 – 100.0)

Proportion of HH with 1 or moremembers without a ration card

6.7% N/A* 18.0%

Average number of days GFR lasts12.6 days

(12.1-13.1)

10.3 days

(9.8-10.7)

9.7 days

(9.1 – 10.3)

Proportion of HH reporting that GFRlasted <15 days

61.8%

(53.1 – 70.6)

93.3%

(89.7 – 97.0)

95.6%

(92.8 – 98.4)

KAMBIOOS - RETROSPECTIVE MORTALITY (~3 MONTH RECALL)

Crude Death Rate (CDR)Deaths/10,000/day (95% CI)

- -0.21

(0.10 - 0.45)Very serious if >1

U5 Death Rate (U5DR)Deaths/10,000/day (95% CI)

- -0.56

(0.24 - 1.31)Very serious if >2

* Result for Proportion of surveyed HH with 1 or more members not registered is not available for Ifo-2 because this question was incorporated only after the first survey (Ifo-2) wascompleted, due to the overwhelming response from Households that the ‘food ration was not big enough’.


RECOMMENDATIONS

Immediate

1. Resume the BSFP for all children aged 6 - 59 months in all camps until levels of GAM fallbelow globally acceptable levels and anaemia drops to below 40%. The decision toreduce the scope of the BSFP from 6-59 to 6-23 months should be reversed in light of thedata on GAM prevalence that shows an elevated prevalence in the older children. (WFP)

2. Urgent monitoring of the BSFP distribution process should be undertaken to investigatereasons for the apparent poor coverage of the programme and to ensure all eligiblechildren are receiving the supplementary food. The reasons for the divergence betweenthe results from the survey data and data from programme monitoring should beinvestigated. (WFP)

3. New surveys in Dagahaley and Ifo camps should be urgently conducted to establish theprevalence of malnutrition and key indicators of programme performance in these camps.(UNHCR)

4. Implementing Partners should be encouraged to deploy more international and seniortechnical staff to Dadaab to ensure adequate monitoring of nutrition and healthprogrammes. This need for international monitoring is particularly acute given thecontinuing involvement of Kenya in the conflict in southern Somalia and the possibility thatthe Government of Kenya may forcibly relocate refugees from Nairobi to Dadaab. (Allpartners)

5. The outreach component of the Nutrition Programs and referral process urgently needs tobe reviewed to improve coverage and targeting of the most vulnerable children. (Healthand Nutrition partners)

6. The hospital in Kambioos should be made operational as soon as possible to facilitatetreatment of complicated cases of severe acute malnutrition. (UNHCR and partners)

7. Distribute additional water containers for household water collection, especially in Ifo-2and Kambioos. (UNHCR and partners)

8. Improve coverage of improved toilet provision. (UNHCR and partners)

Medium term

9. Planning for the next full annual Nutrition Survey, scheduled for August 2013, should bestarted at least 6 months before the implementation date and involve wide consultationwith all IPs and stakeholders at Nairobi and Dadaab levels in order to ensure commitmentand participation. (UNHCR and partners)

10. Expand the use of EPI / health cards for children under five and pregnant/lactatingwomen, to ensure that every child has a card. Emphasis also needs to be placed on theimportance of cards by all stakeholders, in order to increase the presentation of cardswhen needed and the recording of vaccinations and supplementation. (Health andNutrition partners)

11. Nutrition Co-ordinators should give a high priority to staff development for members oftheir nutrition programmes and ensure that adequate training is provided and performancemonitored. (Health and Nutrition partners)


12. Improved reporting of admissions/discharges and mortality to the HIS should be done.(Health and Nutrition partners)

Longer term

13. Strengthen work on IYCF with the aim of further improving feeding practices. (Health andNutrition partners)

14. Explore feasibility of child-spacing and family planning to improve the nutritional status ofwomen and the prenatal and postnatal health of infants.


INTRODUCTION

This report presents the results of three nutrition surveys conducted in Hagadera, Ifo-2 andKambioos camps of the Dadaab Refugee Complex. Coordinated by the United Nations HighCommissioner for Refugees (UNHCR), the surveys took place from 19th September to 8th October2012. Due to the worsening security situation of the wider Dadaab region, like many programs,the UNHCR registration process had been closed since late 2011 leaving many new arrivalsunregistered, thereby being hosted and supported by established households.

At the time of writing, a lengthy verification exercise to confirm the registration of refugees iscontinuing and will be completed for all five camps. With much uncertainty due to interruptedoperations since late 2011, the official population at the time of the data collection was estimatedto be approximately 474,000 people.

The following sections make up the report;

Background: contextual and background information related to the health, nutrition and foodsecurity situation is reported for the Dadaab Complex as a whole.

The methodology for data collection for the surveys was the same in all the camps; however aMortality Questionnaire was additional for Kambioos only.

Results are reported separately for each camp / survey. The discussion refers to all camps and highlights similarities and differences between the

camps. Recommendations are made for Dadaab Complex as a whole due to the similar context of

insecurity and altered service provision. Recommendations for individual camps are alsomade due to two of these camps being newly established since the previous surveys in 2011.

Appendices: contain acknowledgements, tools used, additional information and other relevantdata that supports the main report.

BACKGROUND

The Town of Dadaab is situated in Garissa County, a semi-arid part of North Eastern Kenya,which has a fragile ecological system. Approximately 500 km from Nairobi and 60 km from theSomali border, the Dadaab Refugee Complex now has five refugee camps (Ifo-2, Hagadera, Ifo,Dagahaley and Kambioos), as of early 2012. The five camps now stretch across approximately30 km, with Dagahaley located 15 km to the north of Dadaab town and the newest camp,Kambioos sitting about 15 km south-east of Dadaab town. The region surrounding Dadaab is asemi-arid desert with sparse vegetation and no surface water. Before the establishment of thecamps, the area was used as rangeland by nomadic livestock owners.

The camps were established in 1991/92 to cater for the arrival of refugees from Somalia.Following drought across the Horn of Africa and the resurgence of conflict in Somalia in 2011, theconsequent famine resulted in a large wave of new arrivals during the second half of 2011.Dadaab and the surrounding areas have also experienced a deteriorating security situation. Thekidnapping of two humanitarian aid workers in October 2011 and the targeting of Kenyan Policeby explosive devices severely impacted the delivery of health and nutrition services, and otherprograms throughout 2012 and have faced on-going interruptions.

In fact, the Kenyan Government’s Department of Refugee Affairs closed the reception centre atLiboi (close to the Somali border) in October 2011. A one month registration exercise wasconducted from 4th June to 4th July 2012 with a temporary registration site in Ifo camp set up, andthis saw the registration of 7,971 individuals, more than the 4,066 previously identified forregistration.


Therefore in each camp, UN agencies and partners are still adjusting to the unprecedented influxof about 160,000 refugees experienced from January 2011 to mid-2012 and the immense needsof these vulnerable arrivals.

The total registered population was 474,154 at the end of August 2012, shortly before thesurveys were done. To accommodate the influx and reduce congestion, two more sites – Ifoextension and Kambioos were allocated and opened during 2011, bringing the number of campsto five.

Somali refugees make up the vast majority of the refugee population in the Dadaab camps.Dadaab also hosts other nationalities, including Ethiopians, Sudanese, and Congolese, as well assome refugees from Burundi, Uganda, and Eritrea. Islam is the dominant religion whileChristianity is largely practiced by non-Somali refugees. Although the Somali refugee populationcomprises mainly of nomadic pastoralists, this population also includes farmers, former civilservants, and traders.

The partnership between UNHCR and the World Food Programme (WFP) has continued toensure that food security and other basic needs of the refugees are adequately provided for.WFP is responsible for the provision of the general food ration (GFR) while UNHCR and itspartners provide health services, water and sanitation, shelter, and basic non-food items.

Food Security SituationMany refugees have limited access to employment or additional sources of income. Whilst somefamily members move to Nairobi to find employment, generally the refugees are restricted to therefugee camps with little or no options for establishing a livelihood.

The majority of the refugee population is thus largely dependent on the GFR distributed by WFPas their source of food. During September 2012 (throughout survey data collection), the GeneralFood Distribution (GFD) was the same as during the 2011 nutrition survey; all registered refugeesreceived 560g of food items per person per day as follows in Table 2, providing almost 2,200kcal/day.

Table 1 Contents of the general food ration – Dadaab refugee camps

Food item Grams/person/day KilocaloriesEnergy

Provided (%)Maize meal 210 768 35%Wheat flour 210 764 35%Pulses 60 205 9%Vegetable Oil 35 310 14%CSB 40 150 7%Salt 5 0 -

560 2,197Recommended daily minimum is 2,100 kcal

Each camp had a food distribution point except Kambioos, where residents have to collect theirrations from the Hagadera distribution centre.

Health SituationSignificant improvements and extensions have been made to existing health services in allcamps to help cater for the much greater population since the recent influx of refugees in 2011.All camps have health posts, Kambioos having only one owing to its much smaller population andbeing the newest of the camps. Hagadera continues operating its hospital and a new hospitalhas been constructed in Ifo-2 West. Due to overcrowding in Hagadera camp, there is a seriousstrain on existing health services and it seems likely that further health posts or a second hospitalwill be needed in future.


While each camp has multiple health posts, Ifo-2 East and Kambioos do not have a hospital or a24 hours medical service, requiring refugees to travel or be referred to hospitals in Ifo-2 West andHagadera respectively. At health posts, primary health care services provided to the communityinclude treatment of common illnesses, antenatal care and post natal care, immunization andsupplementary feeding programmes. Despite being fully operational, at times the health posts inthe camps were staffed by incentive staff only due to heightened insecurity and relied on remotetechnical support from qualified staff. This impacted effective service delivery to some extent andinterrupted the accurate and consistent reporting of health statistics since October 2011.

Outbreaks have affected Dadaab camps since 2011 as follows: Cholera outbreak in Hagadera from Oct 2011 to March 2012 with over 1,200 cases

reported Measles outbreak from January 2012 to August affecting mainly Hagadera and Kambioos

populations Six cases of Hepatitis E were detected by the end of August 2012 in Ifo-2 Two cases of Type 2 Polio were confirmed in Ifo-2 Bloody diarrhoea in Ifo-2 from June – August 2012.

The first round of Kenya’s nationwide health promotion campaign ‘Malezi bora’ was held in May2012 and the focus was ‘Together let’s fight malnutrition’, which was fitting for the current Dadaabcontext. Extensive deworming, vitamin A supplementation and measles vaccinations wereachieved during this time, with Ifo-2 Hagadera and Kambioos reaching beyond the 100%coverage planned for some components of the campaign.

The mortality rates recorded by each IP in the Health information System (HIS) in the Dadaabcamps have increased and peaked in December 2011 – January 2012, fitting with the on-goingarrival of refugees who had experienced poor state of health and nutrition for a protracted timebefore leaving Somalia. Kambioos recorded high levels of U5 mortality with rates of 1.4 and 1.7deaths/1,000/month in January and February respectively, but has since been well under 1.0 withthe exception of August when it spiked to 1.9 deaths/1,000/month.

For children under 5 years old, the main causes of illness in 2012 were upper respiratory tractinfections, lower respiratory tract infections, and watery diarrhoea (see Figure 1), making up61.4% of all morbidity under 5 years old, according to HIS data.

Nutrition SituationThe nutrition situation in Dadaab has been improving since 2005, however in 2011 this took aturn for the worse as a result of the significant influx of approximately 150,000 refugees fleeingfrom nearby Somalia and arriving in very poor condition. Consequently, levels of malnutritiondramatically increased during 2011, as shown by the previous nutrition surveys. Copingmechanisms of the established refugee population have continued to be stretched by hosting andsupporting the most recent arrivals since the official registration system was suspended inOctober 2011.


Figure 1 Under-five proportional morbidity from October 2011 to September 2012 - cumulative (UNHCRHealth Information System)

Current Nutrition Services and Activities

Targeted supplementary feeding programmes for moderately malnourished children under5 year olds, pregnant and lactating women and patients with chronic illnesses such as TBand HIV

Outpatient and inpatient therapeutic feeding programmes for severely malnourishedchildren (Stabilization Centres are currently operating in 3 of 5 camps)

Blanket supplementary feeding programme for children 6 - 23 months (lowered from 6 -59 months in Sept 2012)

Infant and young child feeding support and promotion programme Anaemia reduction and control programme for under-5 year olds and pregnant/lactating

women. Biannual Vitamin A supplementation and deworming for under 5 year olds Routine bi-annual mass MUAC screening of children 6-59 months

In 2011, the selective feeding programmes recorded a high number of admissions which wasattributed to the influx of new arrivals. As shown in Figure 2 and Figure 3 below, admissions tothe selective feeding programmes began to increase sharply from mid-late 2011 with about 50%being new arrivals from Somalia.

Rapid Nutrition Assessments Carried Out in 2012From 26th to 30th March 2012 a mass-MUAC screening was carried out by UNHCR and nutritionpartners. MUAC-based SAM estimates were reported to range from 0.5% in Dagahaley to 9.0%in Kambioos and MUAC-based GAM estimates ranged from 3.1% in Dagahaley to 20.6% inKambioos, according to the report.

It is well known that there is a low level of agreement between the malnutrition prevalenceestimated using MUAC and the malnutrition prevalence estimated using weight-for-height z-scores. Therefore, caution was used when considering these results in order to estimate thecurrent GAM levels for planning the 2012 Nutrition survey.


Figure 2 Admissions to community therapeutic care October 2011 to September 2012 (Health InformationSystem)

Figure 3 Admissions to Targeted SFP October 2011 to September 2012 (Health Information System)


SURVEY OBJECTIVES

Primary Objectives

1. To determine the prevalence of acute malnutrition among children 6-59 months.2. To determine the prevalence of stunting among children 6-59 months.3. To investigate IYCF practices among children 0-23 months.4. To assess the prevalence of anaemia among children 6-59 months.5. To assess the prevalence of anaemia among non-pregnant women of reproductive age

(15-49 years).6. To assess the two-week period prevalence of diarrhoea among children 0-59 months.7. To determine the coverage of measles vaccination among children 9-59 months.8. To determine the coverage of de-worming and vitamin A supplementation in the last six

months among children 6-59 months9. To assess the coverage of blanket supplementary feeding programmes for children 6-23

months.10. To determine the coverage of ration cards and the duration the general food ration lasts

for recipient households.11. To determine which coping strategies are used by households to address shortfalls in the

general ration.12. To determine the population’s access to improved water, sanitation and hygiene facilities.13. To assess crude and under-five death rates in the camps in the last three months in

Kambioos.14. To establish recommendations on actions to be taken to address the situation.

Secondary Objectives:

15. To assess the coverage of targeted selective feeding programmes for children 6-59months.

16. To determine the coverage of iron and folate supplementation in pregnant women.

METHODOLOGY

Sample sizeTwo stage cluster surveys were conducted in the 5 camps of Dadaab Complex: Ifo-2, Hagadera,Kambioos, Ifo, and Dagahaley (this report only describes the results from the first 3).

No current ProGres data was available for average HH size and what was available could not beused because the definition of the household in ProGres is based on ration card sharing,whereas in the nutrition survey it is based on “a group of people who live together and routinelyeat out of the same pot”. This latter definition of a household is widely used in nutrition surveysand has been used in Dadaab previously. Similarly, the percentage of U5 was unknown andunable to be estimated with any precision. It was therefore decided that, as in 2011, the quotasampling method was best used to sample from population sub-groups (clusters), rather than thefixed household sampling method.

Calculation of sample sizes for the four population groups to include in the surveys: 1) children 6-59 months, 2) infants 0-5 months and 3) women of reproductive age 15-49 year and 4)households (including mortality for Kambioos, and WASH and food security for all camps) wascompleted and is summarised in tables 2-4. A sample size of households was chosen forassessing WASH and food security indicators based on logistic feasibility. The anaemia samplesize in children aged 6-59 months was the same as the sample size for GAM as is recommendedin the UNHCR Standardised Expanded Nutrition Survey (SENS) guidelines.


Table 2 Sample size justification for household-level indicators

IndicatorC

am

pAssumptions

Assumedcurrentvalue

Desiredprecision

AssumedDEFF

Sample sizeneeded

(households)

Finalsample

sizewithnon-

response rate

Numberrequired

percluster

Mortalityin oneselectedcamp

Kam

bio

os

Rate based onrecentmortality dataof HIS.

Consideredmostvulnerablesub-group withpossibly morerecent arrivals

0.5/10,000/d

Recallperiod of98-104days(WorldRefugeeDay 2012 –20

thJune)

± 0.35/10,000/d

1.5 436(average HHsize assumed

to be 6)

450

(3% HHNRR)

15/cluster

WASHand foodsecurityindicators A

llcam

ps

Use one fixedhouseholdsample basedon feasibility

- - - -360 HH

percamp

12/cluster

Abbreviations: DEFF: design effect; NRR: non-response rate

Table 3 Sample size justification for individual-level indicators (all camps)

Surveytargetgroupand

indicator

Prevalence(%) fromprevious

surveys orassumptions

Assumedcurrentvalue

Desiredprecision

AssumedDEFF

Sample sizeneeded

(individuals)

Finalsample

sizewithNRR

Numberrequired

per cluster

Acutemalnutrition inchildren6-59months

See Table 4below

HAG:20%KAM:23%IFO-2:25%

HAG,KAM,IFO-2:±5%

2.0HAG: 535IFO-2: 627KAM: 593

600 forallcamps(10%NRR)

20/cluster

IYCF inchildren0-5months

Convenientsampledetermined by6-59 monthssample sizes

(infants 0-5months shouldcompriseabout 25% ofthe total 300infantsneeded)

- - - -

300infantspercamp

4 / cluster

(additionalinfants 0-5months tocompletesample)

Anaemiain women15-49years

Based onanaemia innon-pregnantwomen fromthe 2011

50% ± 9% 2.0258 women

required

300womenpercamp

10/cluster


survey.Assumedpregnancy andlactationprevalence of30% hencesample sizemultiplied by1.3

Abbreviations: DEFF: design effect; NRR: non-response rate; ANC: Antenatal Care

Table 4 Sample size justification and rationale for acute malnutrition in children 6-59 months

Camp Description Nutritionsurveys Aug /Sep 2011

Estimatedprevalence, desiredprecision and DEFF

SamplesizewithNRR

IFO-2(Survey 1)

Based on MUAC screeningMarch 2012, GAM of 13.1%and SAM of 4.5% and at riskof malnutrition were 24.5%

GAM estimated to be ~25%or lower.

N/A

(thispopulationwerepredominantlyresettled fromDagahaleyoutskirts –38% GAM in2011)

2.0 – assumingheterogeneityparticularly betweenIfo 2 East and Ifo 2West

25%, ±5, DEFF 2.0

627

KAM(Survey 3) Based on MUAC screening

of children 6-59 monthsMarch 2012 – GAM – 20.6%and SAM – 9.0% at risk ofmalnutrition is 21.0%.

GAM estimated to be ~23%or lower

N/A23%, ±5%, DEFF 2.0 593

HAG(Survey 4) Based on MUAC screening

of children 6-59 monthsMarch 2012 – GAM – 5.6%and SAM – 1.4% at risk ofmalnutrition is 14.4%.

GAM estimated to be ~15%or lower

GAM – 17.2%SAM – 4.6%

20%, ±5%, DEFF 2.0 535

Rationale Expectation that prevalence estimate based on WHZ will give a higher prevalencethan that based on MUAC.

Expectation that there is significant heterogeneity in malnutrition within the camps,hence the use of a design effect of 2, due to some unregistered households andcontinued hosting of new arrivals (not yet registered)

Abbreviations: DEFF: design effect; NRR: non-response rate; KAM: Kambioos; HAG: Hagadera.

Sampling procedure: selecting clustersDue to the large number of indicators and based on the pre-testing of the questionnaires, it wasestimated that no more than 12 households could be surveyed in one day by each team. Hence,a total of 30 clusters were randomly selected in each of the five camps using probability


proportional to size (PPS). Clusters were allocated to blocks according to their population size, asrecorded in the UNHCR ProGres database at the time of planning.

Some editing of the ProGres database was required; for example there were very few residentslisted in some Blocks, and these were considered errors in the database. In addition, there wasthe occasional Block that did not actually exist and these were removed from the sampling frame.These adjusted population estimates were used in cluster allocation calculations conducted inENA for SMART. See Appendix 4 for the listing of clusters used.

Sampling procedure: selecting households and individualsAs the blocks structures remained unchanged in four of the Dadaab camps; blocks are usuallyrectangular in shape with narrow paths going across them – the same method was used as in the2011 Nutrition Survey. For consistency, second stage sampling was performed using the sameadapted version of the standard EPI (spin the pen) method to select the households to survey. Toselect the first household to survey, the survey teams walked around the perimeter of the blockand assigned a number to each path entering the block. A path was selected randomly usingrandom numbers and the team then walked down that path assigning a number to eachcompound door found on the left and on the right until the end of the path was reached or untilthe first intersection with another path. The first household was then selected by choosing ahousehold number using random numbers. If this was a compound, each individual householdwas surveyed. After leaving, subsequent households were selected by walking out of the samecompound door, turning left out of the household, following the path and selecting the next houseon the left-hand side.

In Kambioos only, the most recently constructed camp where refugees continue to be relocatedto, the blocks are organised a little differently – in a more geometrical pattern with many morepathways entering each block. It was therefore decided that following the random selection of theentry path, only households on the left would be numbered and this was done until the teamreached an exit to the block. This meant walking in a U-shape from point of entry. (SeeAppendix 6 for a plan of Kambioos blocks).

In all surveys, standardised procedures were followed by all teams. All households wereselected, whether or not they had an eligible individual, until the quota for the household indicatorwas reached. All eligible individuals within the selected households were measured until thequota for that target group was reached. When a household was visited to get the last individualfor the target group quota and there were several eligible individuals in the household, all weremeasured and included in the sample to avoid the possibility of selection bias and unequalselection probability.

If an individual or an entire household was absent, the teams were instructed to return to theabsent household or revisit the absent individual up to two times on the same survey day. If theywere unsuccessful after this, the individual or the household were recorded as an absence andthey were not replaced with another household or individual.

If an individual or an entire household refused to participate, then it was considered a refusal andthe individual or the household were not replaced with another household or individual.

If a selected household was abandoned, the household was replaced by another household.

If a selected child was disabled with a physical deformity preventing certain anthropometricmeasurements, the child was still included in the assessment of other indicators.

QuestionnairesThe paper versions of the questionnaires are included in Appendix 7, along with the householdlisting form and cluster control sheets, which were used to monitor field work progress.


The questionnaires were prepared on paper in English before being coded as electronicquestionnaires in Open Data Kit Collect (ODK Collect) and uploaded onto Android smart phonesfor testing. The questionnaires were revised with the input of Supervisors and Team Leaders andthen piloted by teams in two to three households before the survey. Data validation ranges andskip patterns were coded in the questionnaires to help reduce data entry errors. Following pilotingand several rounds of revision, the electronic questionnaires were finalised. They wereadministered in Somali via translators if required – many team members spoke Somali andassociated dialects.

Four Questionnaires were created and administered in Ifo-2 and Hagadera to provide informationon the relevant indicators for the different target groups. Five questionnaires were used inKambioos where an additional mortality questionnaire was included. Data on time of arrival in thecamp and ethnicity were collected in the different modules.

It was decided not to determine long-lasting insecticidal net (LLIN) coverage in the present surveydue to the already extensive length of the survey and in light of the security concerns. It was alsonot identified as a priority by the IPs. During discussions with stakeholders at the survey planningstage, IPs had prioritised the IYCF module for inclusion due to the implementation of a IYCFprogram by ACF during the previous 12 months.

Questionnaire 1: Household Food Security and WASH- This included questions on access anduse of the GFD ration and coping mechanisms when the general ration ran out prior to the nextdistribution. A shortened version of the SENS WASH questionnaire was undertaken inhouseholds and included questions on availability of jerry-cans, access to improved drinkingwater source, satisfaction with the water supply, type and quality of excreta disposal facilities inuse and coverage of soap distribution.

Questionnaire 2: Women 15-49 years - This included questions and measurements on womenaged 15-49 years. Information was collected on women’s pregnancy and lactating status,coverage of iron-folic acid pills and post-natal vitamin A supplementation, and haemoglobinassessment for non-pregnant women only.

Questionnaire 3: Children 6-59 months - This included questions and measurements on childrenaged 6-59 months. Information was collected on anthropometric status, oedema, enrolment inselective feeding programmes and coverage of blanket supplementary feeding programmes(CSB++), immunisation (measles and PENTA), vitamin A supplementation and deworming in lastsix months, morbidity from diarrhoea in past two weeks, haemoglobin assessment (for 6-59months), and feeding practices for infants (6-23 months).

Questionnaire 4: Infant 0-5 months - This included questions on breastfeeding practices,introduction of solid foods and other aspects of infant feeding for children aged 0-5 months..

Questionnaire 5: Mortality - This included questions related to mortality in the last three monthsamong the population of Kambioos camp only. The memorable date chosen to define the recallperiod was World Refugee Day on 20th June. The questionnaire was combined with thehousehold listing form used in the other camps and to save time during the survey planningstage, it was administered on paper, instead of being converted to an electronic form.

Measurement methods for household-level indicators:

Food security: The questionnaire used was based on UNHCR SENS Food SecurityQuestionnaire, yet was reduced and combined with WASH questionnaire to form the ‘Household


Questionnaire’. Discussions with stakeholders, the most important one being WFP, led to therevised food security questions whilst attempting to retain as much similarity as possible toprevious questionnaires for comparison.

WASH: The questionnaire used was an adapted version of UNHCR SENS Guidelines, and wasdeveloped in consultation with UNHCR WASH unit. Similar to the Food Security, the WASHquestionnaire was contracted and combined in an attempt to contain the overall time required tocomplete all questionnaires for one household. The decision to include WASH questions wasrelated to the recent outbreak of Hepatitis E reported in at least one camp and with considerationthat two camps are newly established since the last survey.

Mortality: An individual-level mortality form was merged with the household listing form to allowthe mortality data to be collected most efficiently, as the household members were already beinglisted on that form, including gender and age. Kambioos was chosen as it was thought to havebeen worst affected with respect to mortality, as it was the last camp to be set up and populatedwith less services running compared to the more established camps. Data entry and analysis wasdone in ENA for SMART with the individual level data derived from the adapted HH listing form(see appendix 7).

Measurement methods for individual-level indicators:

Sex of children: Gender was recorded as male or female.

Birth date or age in months for children 0-59 months: The exact date of birth (day, month,year) was recorded from either an EPI card, UNHCR manifest (if not 1st January), child healthcard or birth notification if available. If no reliable proof of age was available, age was estimatedin months using a local event calendar (see Appendix 8) or by comparing the selected child witha sibling whose ages were known, and was recorded in months on the questionnaire.

Age of women 15-49 years: Unlike small children, the exact date of birth of women was notrecorded. Reported age was recorded in years.

Weight of children 6-59 months: Measurements were taken to the closest 100 grams usingnew electronic scales (SECA scale) with a wooden board to stabilise it on the ground. Somechildren were weighed with clothes due to the cultural sensitivities of removing clothes and thiswas noted. Previous experience in Dadaab has shown that it can be difficult to convincecaregivers to remove clothes from children during weighing in nutrition surveys. The meanweight of samples of typical clothes from children 6 – 59 months was used to identify anadjustment figure. The weight of 117 grams (the same used in 2011) was used to adjust ifweighed with clothes.

Height/Length of children 6-59 months: Children’s height or length was taken to the closestmillimetre using a wooden height board. A height stick and the age of the child were used todecide whether a child should be measured lying down (length) or standing up (height). Childrenless than 87 cm were measured lying down, while those greater than or equal to 87 cm weremeasured standing up.

Oedema in children 6-59 months: bilateral oedema was assessed by measurers applyinggentle thumb pressure on to the tops of both feet of the child for a period of three seconds thenobserving for the presence or absence of a pit. All oedema cases reported by the survey teamswere verified by the survey coordinators and were referred immediately.

MUAC of children 6-59 months: MUAC was measured at the mid-point of the left upper armbetween the elbow and the shoulder and taken to the closest millimetre using a standard MUACtape. MUAC was recorded in centimetres.


Child enrolment in selective feeding programme for children 6-59 months: Selective feedingprogramme coverage was assessed for the outpatient therapeutic programme and for thetargeted supplementary feeding programme using the direct method.

Haemoglobin (Hb) concentration in children 6-59 months and non-pregnant women 15-49years: Hb concentration was taken from a capillary blood sample from the fingertip and recordedto the closest gram per decilitre by using the portable HemoCue Hb 301 Analyser (HemoCue,Sweden). If severe anaemia was detected, the child or the woman was referred immediately.

Measles vaccination in children 6-59 months: Measles vaccination was assessed by checkingfor the measles vaccine on the EPI card if available or by asking the caregiver to recall if no EPIcard was available.

PENTA vaccination in children 6-59 months: The PENTA vaccination contains fivecomponents: Diphtheria, Pertussis, Tetanus, Hepatitis B, Haemophilus Influenza Type b and isgiven in three doses on three different occasions. PENTA vaccination was assessed by checkingfor the first, second, or third PENTA dose and was only recorded as ‘yes’ when confirmed byexamination of the vaccination card.

Vitamin A supplementation within last 6 months in children 6-59 months: the receipt ofvitamin A supplementation within the last 6 months was checked by the EPI or health card (ifdocumented) and also via recall by the child’s caregiver if no card was available (without showinga Vitamin A capsule).

Deworming in last 6 months in children 24-59 months: receipt of a deworming pill within thepast six months was determined by recall only in this year’s survey, as it was not consistentlyrecorded on the EPI / health cards.

Diarrhoea in last 2 weeks in children 0-59 months: Caregivers were asked if their child hadsuffered from diarrhoea in the past two weeks and were asked about feeding practices duringdiarrhoea.

ANC enrolment and iron and folic acid pills coverage: If the surveyed woman was pregnant,enrolment in the ANC programme and receipt of iron-folic acid pills was assessed by card orrecall.

Post-natal vitamin A supplementation: If the surveyed woman had delivered a baby in the lastsix months, it was assessed by card or recall whether she had received vitamin Asupplementation.

Infant and young child feeding practices in children 0-23 months: Infant and young childfeeding practices were assessed based on standard WHO recommendations (WHO 2007) aswas used in previous years in Dadaab.

Referrals: Children aged 6-59 months were referred to health posts for treatment when MUACwas < 12.5 cm, when oedema was present, or when haemoglobin was < 7.0 g/dL. Women ofreproductive age were referred to the hospital for treatment when haemoglobin was < 8.0 g/dL.

Case definitions and calculations

Mortality: The crude death rate (CDR) and the U5 death rate (U5DR) were expressed as thenumber of deaths per 10,000 people per day. The formula below was applied:


Crude Death Rate (CDR) = 10,000/a*f/ (b+f/2-e/2+d/2-c/2)Where:a = Number of recall daysb = Number of current household residentsc = Number of people who joined household during recall periodd = Number of people who left household during recall periode = Number of births during recall periodf = Number of deaths during recall period

Malnutrition in children 6-59 months: Acute malnutrition was determined using the globallyaccepted measure of weight-for-height index values (z-scores) or the presence of oedema andclassified as shown in Table 5. Main results are reported following analysis using the WHO 2006Growth Standards.

Table 5 Definitions of acute malnutrition using weight-for-height and/or oedema in children 6-59 months

Categories of acutemalnutrition

Percentage ofmedian (NCHS

Growth Reference1977 only)

Z-scores (NCHS GrowthReference 1977 and WHOGrowth Standards 2006)

Bilateraloedema

Global acute malnutrition <80% < -2 z-scores Yes/No

Moderate acute malnutrition <80% to ≥70% < -2 z-scores and ≥ -3 z-scores No

Severe acute malnutrition>70% > -3 z-scores Yes

<70% < -3 z-scores Yes/No

Stunting, also known as chronic malnutrition, was defined using height-for-age index values andwas classified as severe or moderate based on the cut-offs shown in Table 6. Then results arereported according to the WHO Growth Standards 2006.

Table 6 Definitions of stunting using height-for-age in children 6–59 months

Categories of stuntingZ-scores (WHO Growth Standards2006 and NCHS Growth Reference

1977)

Stunting <-2 z-scores

Moderate stunting <-2 z-score and >=-3 z-score

Severe stunting <-3 z-scores

Underweight was defined using the weight-for-age index values and was classified as severe ormoderate based on the cut-offs shown in Table 7. Main results are reported according to theWHO Growth Standards 2006.

Table 7 Definitions of underweight using weight-for-age in children 6–59 months

Categories of underweightZ-scores (WHO Growth Standards2006 and NCHS Growth Reference

1977)

Underweight <-2 z-scores

Moderate underweight <-2 z-scores and >=-3 z-scores

Severe underweight <-3 z-scores

Mid Upper Arm Circumference (MUAC) values in children 6-59 months were used to definemalnutrition according to the cut-offs shown in Table 8.


Table 8 Classification of acute malnutrition based on MUAC in children 6-59 months (WHO)

Categories of Malnutrition MUAC Reading

Moderate malnutrition ≥ 11.5 cm and <12.5 cm

Severe malnutrition < 11.5 cm

Child enrolment in selective feeding programme for children 6-59 months:Selective feeding programme coverage was assessed using the direct method as follows:

Coverage of TSFP programme (%) =100 x No. of surveyed children with MAM according to TSFP admission criteria who reported being registered in SFP

No. of surveyed children with MAM according to TSFP admission criteria

(This calculation excludes children already enrolled in the OTP program as they cannot be eligible for bothprogrammes at the same time, and would be in the recovery phase).

Coverage of OTP programme (%) =100 x No. of surveyed children with SAM according to OTP admission criteria who reported being registered in OTP

No. of surveyed children with SAM according to OTP admission criteria

Infant and young child feeding practices in children 0-23 months:Infant and young child feeding practices were assessed as follows based on standard WHOIndicators for Assessing IYCF practices (2010).

WHO core indicator 1. Early initiation of breastfeeding:

Proportion of children 0-23 months who were put to the breast within one hour of birth.

Children 0-23 months who were put to the breast within one hour of birth

Children 0-23 months

WHO core indicator 2. Exclusive breastfeeding under 6 months:

Proportion of infants 0–5 months of age who are fed exclusively with breast milk: including milk expressed or from a

wet nurse, ORS, drops or syrups (vitamins, minerals, medicines)

Infants 0–5 months of age who received only breast milk during the previous day

Infants 0–5 months of age

WHO core indicator 3. Continued breastfeeding at 1 year:

Proportion of children 12–15 months of age who are fed breast milk.

Children 12–15 months of age who received breast milk during the previous day

Children 12–15 months of age

WHO core indicator 4. Introduction of solid, semi-solid or soft foods:

Proportion of infants 6–8 months of age who receive solid, semi-solid or soft foods.

Infants 6–8 months of age who received solid, semi-solid or soft foods during the previous day

Infants 6–8 months of age

WHO optional indicator 9. Children ever breastfed:

Proportion 0-23 months who were ever breastfed.

Children 0-23 months who were ever breastfed

Children 0-23 months

WHO optional indicator 10. Continued breastfeeding at 2 years:

Proportion of children 20–23 months of age who are fed breast milk.

Children 20–23 months of age who received breast milk during the previous day


WHO optional indicator 14. Bottle feeding:Proportion of children 0-23 months of age who are fed with a bottleChildren 0–23 months of age who were fed with a bottle during the previous day



Diarrhoea: Three or more loose or watery stools in a 24-hour period.

Continued feeding during diarrhoea: Breastfeeding or food offered at about the same orgreater frequency during diarrhoea as before diarrhoea started (FANTA 1999).

Anaemia in children 6-59 months and women of reproductive age: Anaemia was classifiedaccording to the cut-offs in children 6-59 months and non-pregnant women of reproductive ageshown in Table 9. Pregnant women are not included in routine UNHCR nutrition surveys for theassessment of anaemia due sample size issues (usually a small number of pregnant women arefound) as well as the difficulties in assessing gestational age in pregnant women.

Table 9 Definition of anaemia (WHO 2000)

Age/Sex groupsCategories of Anaemia (Hb g/dL)

Total Mild Moderate SevereChildren 6 - 59 months <11.0 10.9 - 10.0 9.9 - 7.0 < 7.0Non-pregnant adult females 15-49 years <12.0 11.9 - 11.0 10.9 - 8.0 < 8.0

Classification of public health problems and targets

Mortality: The thresholds used for mortality are shown in Table 10.

Table 10 Mortality benchmarks for defining crisis situations (NICS, 2010)

Emergency thresholdCDR > 1/10,000 / day: ‘very serious’CDR > 2 /10,000 /day: ‘out of control’CDR > 5 /10,000 /day: ‘major catastrophe’(double for U5MR thresholds)

Anthropometric data: UNHCR Strategic Plan for Nutrition and Food Security (2008-2012) statesthat the target for the prevalence of global acute malnutrition (GAM) for children 6-59 months ofage by camp, country and region should be < 5% and the target for the prevalence of severeacute malnutrition (SAM) should be <1%. Table 11 shows the classification of public healthsignificance of the anthropometric results for children under-5 years of age according to WHO.

Table 11 Classification of public health significance for children under 5 years of age (WHO 1995, 2000)

Prevalence % Critical Serious Poor AcceptableLow weight-for-height ≥15 10-14 5-9 <5 Low height-for-age ≥40 30-39 20-29 <20 Low weight-for-age ≥30 20-29 10-19 <10

Selective feeding programmes: UNHCR Strategic Plan for Nutrition and Food Security 2008-2012 includes the following indicators:

% of targeted supplementary feeding programmes that meet SPHERE standards forperformance: recovery >75%, case fatality <3%, defaulter rate <15%, and coverage>90% for camps – by camp and country.

% of programmes for management of SAM that meet SPHERE standards forperformance and adhere to standard treatment protocols: recovery >75%, case fatality<10%, defaulter rate <15%, and coverage >90% for camps regardless of whether facilitybased or community based – by camp or facility (if non camp-based).

Measles vaccination coverage: UNHCR recommends target coverage of 95% (same as SphereStandards).


Vitamin A supplementation coverage: UNHCR Strategic Plan for Nutrition and Food Security(2008-2012) states that the target for vitamin A supplementation coverage for children aged 6-59months by camp, country and region should be >90%.

Anaemia data: UNHCR Strategic Plan for Nutrition and Food Security (2008-2010) states thatthe targets for the prevalence of anaemia in children 6-59 months of age and in women 15-49years of age should be low i.e. <20%. The severity of the public health situation should beclassified according to WHO criteria as shown in Table 12.

Table 12 Classification of public health significance (WHO 2000)

Prevalence % High Medium LowAnaemia ≥40 20-39 5-19

WASH: Diarrhoea caused by poor water, sanitation and hygiene, globally accounts for the annualdeaths of over two million children under five years old. Diarrhoea also contributes to high infantand child morbidity and mortality by directly affecting their nutritional status. Refugee populationsare often more vulnerable to public health risks and reduced funding can mean that long termrefugee camps often struggle to ensure the provision of essential services, such as water,sanitation and hygiene. Hygienic conditions and adequate access to safe water and sanitationservices is a matter of ensuring human dignity and is recognised as a fundamental human right.The standards (amongst others) shown in Table 13 apply to UNHCR WASH programmes.

Table 13 UNHCR WASH Programme Standards

UNHCR Standard IndicatorLatrine provision 20 people/latrine

Soap provision > 250 g per person per month

Training, coordination and supervision

Coordination of the surveys was conducted from UNHCR Dadaab Sub-Office (SO) by theUNHCR Nutritionist (Mary Koech) with technical support from an UCL team of two consultants(Jo McElhinney and Andrew Seal), one CartONG Consultant (Sandra Sudhoff) and logisticssupport from ADEO (Mary Orwenyo). The UCL team were instructed by UNHCR that visits to thecamp were not permitted due to the security situation.

The surveys were undertaken by five teams per camp (total of 25 teams) drawn from eachagency’s staff or daily workers; IRC, GIZ, MSF-CH, KRCS, IMC. Each team was composed offive members; a team leader, a mobiliser/translator, two measurers and one HemoCue operator.The supervision of data collection was conducted by the nutritionists from each of the five leadagencies. In addition, there was additional support by one UNICEF Nutritionist (Francis Kidake),two ADEO Nutritionists and an ADEO nurse, one WFP Nutritionist (Colin Buleti) and the UNHCRNutritionist (Mary Koech) on a daily basis throughout the data collection period.

The team leader was the interviewer for all questionnaires and entered the responses into theAndroid phone after completing the HH listing form (Appendix 7). The team leader worked withthe translator/mobiliser who at times assisted with recording the HH listing form. The other teammembers were occupied with taking their respective measurements. All team members wereliterate and some had previous experience conducting surveys.

A standardised training lasting four days was provided to Supervisors and Team Leaders at theDadaab SO. This was followed by training of measurers in the field by the Supervisors and TeamLeaders, and thereafter by a day of Standardisation testing and then one day of piloting.

Training lasted from September 12th – 15th and the Standardisation test and pilot day were heldduring the two days prior to each survey starting.


Whilst the measurers were being trained in the camps, two sessions of training for the HemoCueOperators were conducted at Dadaab SO, with staff from GIZ, IRC and MSF, and who wereeither Laboratory staff, Community Health workers or Auxiliary Nurses.

Due to the extended time-frame for data collection and the volume of material covered during theinitial training, refresher training was held for the four surveys during the final days of the previoussurvey. This allowed improvements to be made and issues to be raised in time for eachsubsequent survey and attention to be paid to particular areas of difficulty or potential error.

The initial training covered: the purpose and objectives of the survey; roles and responsibilities ofeach team member; designing and fine-tuning each question including responses of thequestionnaires; interviewing skills and recording of data; designing and use of calendar of eventsfor age determination; correct techniques for taking anthropometric measurements and commonerrors; and sampling procedures. The practical session on haemoglobin measurements involvedthe trainees and trainers acting as volunteers for practice sessions as well as a standardisationexercise.

One day was set aside for the standardisation test for anthropometry as recommended bySMART and UNHCR SENS guidelines. Due to the insecurity and lack of supervision from thesurvey manager, it was decided that an adapted standardisation test would be conducted. Thisinvolved the measurers working in pairs instead of as individuals, and also measuring threechildren twice each.

For the pilot test, two to three households were selected by each of the teams who administeredthe questionnaires and took the required measurements. The data collection tools were thenreviewed based on the feedback from the field piloting.

Two stage cluster surveys were conducted in all five camps in Dadaab (Hagadera, Ifo,Dagahaley, Ifo 2, and Kambioos). It is important to note that the surveys did not include theoutskirt areas of Dagahaley, Hagadera, or Ifo camps as they are no longer recognised as areasfor refugees to reside (and most have been relocated) and also due to a lack of validatedpopulation data for these areas. Although five surveys were conducted, concerns were raisedregarding the quality of data in Dagahaley and Ifo camps and UNHCR made the decision not torelease these results.

Data collection lasted six days per camp with one camp undertaken during the first week (19th –24th September), to allow any arising problems to be addressed. This was followed by surveys inKambioos and Dagahaley from 26th Sept – 1st October and finally Hagadera and Ifo wereconducted from 3rd – 8th October. Upon entering the household, each survey team explained thepurpose of the survey and the confidentiality agreement, and then obtained verbal consent beforeproceeding with the survey in the selected households.

Data Collection using Android phonesIn contrast to the 2011 Nutrition Survey in Dadaab, Android phones (also known as Smartphones) were used to collect data in the form of electronic questionnaires. CartONG the partneragency to provide all technical support, was responsible for setting up of equipment, pre-testingthe system once set up, training the teams and survey management team and also coding thequestionnaires from paper format.

Whilst this process was very technical and required extra logistics and human resources it greatlyreduced the time usually required for data entry, and also appeared to help to minimise errors bythe teams entering data.

ODK was the Android application used to produce the questionnaires and collect data, and theAndroid phones were either Motorola Milestone or HTC Desire Z. Both models were used assome problems were initially encountered with preparing the new HTCs for use, whereas theolder Motorola’s had been used in surveys elsewhere and were considered a reliable option.


Data analysisData entry was checked and then confirmed at UNHCR Dadaab SO each evening upon receivingthe phones from the field. Each record was checked against the paper Household Listing formand either confirmed or marked to be returned to the team for correction and/or confirmation thefollowing day. By sending the Android phones back to the teams with corrections or confirmationsrequired, the teams received practical feedback and further learned the importance of accuracyand thoroughness in recording the measurements and responses.

Records for each questionnaire in each household were checked for completeness, consistencywith HH listing form, and range of data, before being confirmed and synchronised (uploaded)from the phones to the server each evening.

Records were downloaded from the server at the conclusion of each evening as .csv files toserve as a back-up and minimise the risk of loss of data from the server. Data for children 6-59months were then transferred from the .csv files into ENA for SMART software (versionNovember 24th 2012) each evening by the coordination team for a Plausibility check to begenerated, which was used to provide daily feedback to the Supervisors.

At the end of day six of data collection, a complete set of data was ready for the next stage of‘cleaning’. All data files were cleaned before analysis. Entries were double checked, one by one,with the original questionnaire to ensure there were no data entry errors. Duplicate entries wereidentified in Excel and removed.

Analysis was performed using ENA for SMART and Epi Info software. The SMART PlausibilityReport was generated for each complete set of survey data in order to check the quality of theanthropometric data and a summary of the key quality criteria is shown in Appendix 2.

The nutritional indices from this year's surveys have been cleaned using flexible cleaning criteriafrom the observed mean (also known as SMART flags in the ENA for SMART software), ratherthan the reference mean (also known as WHO flags in the ENA for SMART software).

This flexible cleaning approach is recommended in the UNHCR SENS Guidelines (Version 1.2,June 2011) in accordance with SMART recommendations. For the weight-for-height index, acleaning window of +/- 4 SD was used again instead of the default +/- 3 SD value contained inthe SMART for ENA software for comparability reasons. In 2011, a wider cleaning window wasalso applied which is consistent with WHO recommendations. This was appropriate as the targetpopulation in the refugee camps and the new arrivals were considered, (1) likely to be sufferingfrom high levels of severe acute malnutrition, and (2) likely to be heterogeneous, with some sub-groups more seriously affected than others. In such situations, using the default +/- 3 SD cleaningwindow is inappropriate and likely to lead to the exclusion of some true cases of severe acutemalnutrition.


RESULTS FROM HAGADERA CAMP, DADAAB (OCT 2012)

INDIVIDUAL-LEVEL INDICATORS:CHILDREN 6-59 MONTHS,INFANTS 0-23 MONTHS,WOMEN OF REPRODUCTIVE AGE 15-49 YEARS

HOUSEHOLD INDICATORS: WASH AND FOOD SECURITY

Table 14 provides the planned sample size and the actual units sampled during the survey foreach target population group. Thirty clusters were sampled for all indicators, therefore thenumber of required records per cluster varied according to the total target sample size required.

Table 14 Target sample size and actual number captured during the survey - Hagadera camp, Dadaab(Oct 2012)

Target group Targetsample size

Subjectsmeasured/interviewed

during the survey

% of the target

Children 6-59 months 600 600 100%Children 0-23 months 300 320 107%Women 15-49 years 300 306 102%

CHILDREN 6-59 MONTHS - HAGADERA CAMP, DADAAB (OCT 2012)

Outlined below in Table 15 is the demographic data of children surveyed: nationality, time ofarrival to Dadaab and the region of origin if recently arrived (i.e. within past 12 months).

Table 15 Demographic information - Hagadera camp, Dadaab (Oct 2012)

Number/total %Nationality

Somali 462 / 600 77.0Somali Bantu 138 / 600 23.0Others 0 / 600 0.0%

Arrival in camp<3 months 2 / 600 0.33-6 months 4 / 600 0.76-12 months 2 / 600 0.3>12 months 592 / 600 98.7

Region of origin forchildren in camp for<12 months

Lower Juba 7 / 8 87.5Middle Juba - -Gedo 1 / 8 12.5Bay - -Bakool - -Lower Shabelle - -Middle Shabelle - -Hiraan - -Mogadishu/Banadir - -Other - -

Anthropometric results (based on WHO Growth Standards 2006)The coverage of age documentation was high with 81% of children having an exact birth date.The age group 18 – 29 months was slightly over-represented and 42-53 months under-represented. There were equal numbers of boys and girls represented in the survey in


Hagadera, shown in Table 16 below, by the sex-ratio of 1.02 (within the accepted range of 0.8 –1.2).

Table 16 Distribution of age and sex of sample - Hagadera camp, Dadaab (Oct 2012)

Boys Girls Total RatioAGE(months)

no. % no. % no. % Boy:girl

6-17 64 47.1 72 52.9 136 22.7 0.8918-29 74 47.4 82 52.6 156 26.0 0.9030-41 64 49.6 65 50.4 129 21.5 0.9842-53 65 58.0 47 42.0 112 18.6 1.3854-59 36 53.7 31 46.3 67 11.2 1.16Total 303 50.5 297 49.5 600 100.0 1.02

Table 17 below, shows that compared with results from the 2011 survey, there has been asignificant decrease in GAM (from 17.2%, 95% CI: 13.2 – 22.1 to 10.3%, 95% CI: 8.0 – 13.0)(p<0.05), among children in Hagadera, aged 6-59 months.

Table 17 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and bysex - Hagadera camp, Dadaab (Oct 2012)

Alln = 594

Boysn = 299

Girlsn = 295

Prevalence of global malnutrition(<-2 z-score and/or oedema)

N = 6110.3%

(8.0 – 13.0)

N = 3612.0%

(9.0 – 16.0)

N = 258.5%

(5.7 – 12.3)Prevalence of moderate malnutrition(<-2 z-score and >=-3 z-score, nooedema)

N = 427.1%

(5.2 – 9.6)

N = 279.0%

(6.1 – 13.1)

N = 155.1%

(3.0 – 8.4)Prevalence of severe malnutrition(<-3 z-score and/or oedema)

N = 193.2%

(1.9 – 5.2)

N = 93.0%

(1.7 – 5.3)

N = 103.4%

(1.7 – 6.5)

The prevalence of oedema is 0.5 % (n=3)

Whilst there has been a decrease in GAM since the 2011 survey, the levels have not returned tothe pre-2011 influx seen in the 2010 nutrition survey as seen in Figure 4.

Figure 4 Trends in GAM and SAM since 2009 - Hagadera camp, Dadaab (Oct 2012)


The number of cases of severe and moderate wasting, as seen in Table 18, are higher in theyounger age-groups, particularly in the 6-17 month age group. In this sample it appears that theprevalence (%) is also high in the 54 – 59 month age-group, as seen in the Figure below. This isthe same pattern as seen in the 2011 nutrition survey.

Table 18 Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema -Hagadera camp, Dadaab (Oct 2012)

Severe wasting(<-3 z-score)

Moderatewasting

(>= -3 and <-2 z-score )

Normal(> = -2 z score)

Oedema

Age(months)

Totalno.

No. % No. % No. % No. %

6-17 134 4 3.0 11 8.2 117 87.3 2 1.518-29 154 5 3.2 11 7.1 137 89.0 1 0.630-41 129 5 3.9 5 3.9 119 92.2 0 0.042-53 111 0 0.0 8 7.2 103 92.8 0 0.054-59 66 2 3.0 7 10.6 57 86.4 0 0.0Total 594 16 2.7 42 7.1 533 89.7 3 0.5

Figure 5 Trends in the prevalence of wasting by age in children 6-59 months - Hagadera camp, Dadaab(Oct 2012)

Table 19 Distribution of severe acute malnutrition and oedema based on weight-for-height z-scores -Hagadera camp, Dadaab (Oct 2012)

<-3 z-score >=-3 z-scoreOedema present Marasmic kwashiorkor

N = 0Kwashiorkor

N = 3Oedema absent Marasmic

N = 17Not severely malnourished

N = 577

Figure 6 shows that the weight-for-height z-score distribution is shifted to the left, illustrating apoorer nutritional status than the international WHO Standard (2006) population of children aged6-59 months.


Figure 6 Distribution of weight-for-height z-scores (based on WHO Growth Standards; the referencepopulation is shown in green) of survey population compared to reference population-Hagadera camp,Dadaab (Oct 2012).

Table 20 Prevalence of stunting based on height-for-age z-scores and by sex - Hagadera camp, Dadaab(Oct 2012)

Alln = 576

Boysn = 291

Girlsn = 285

Prevalence of stunting(<-2 z-score)

n = 14825.7%

(20.4 – 31.8)

n = 8830.2%

(23.8 – 37.6)

n = 6021.1%

(15.3 – 28.3)Prevalence of moderate stunting(<-2 z-score and >=-3 z-score)

n = 10618.4%

(14.4 – 23.3)

n = 6622.7%

(17.6 – 28.7)

n = 4014.0%

(9.4 – 20.4)Prevalence of severe stunting(<-3 z-score)

n = 427.3

(5.2 – 10.1)

n = 227.6%

(5.0 – 11.2)

n = 207.0%

(4.6 – 10.5)

Table 21 Prevalence of stunting by age based on height-for-age z-scores - Hagadera camp, Dadaab (Oct2012)

Severe stunting(<-3 z-score)

Moderate stunting(>=-3 and <-2 z-

score)


Age (months) Totalno.

No. % No. % No. %

6-17 130 10 7.7 23 17.7 97 74.618-29 148 16 10.8 28 18.9 104 70.330-41 124 9 7.3 24 19.4 91 73.442-53 109 3 2.8 23 21.1 83 76.154-59 65 4 6.2 8 12.3 53 81.5Total 576 42 7.3 106 18.4 428 74.3

Children aged 6-29 months were most affected by severe stunting followed by children 30-41months, and this is consistent with the age groups showing higher rates of stunting in the 2011surveys. The overall change in stunting levels are not statistically significant; severe stunting was6.3% (95% CI: 4.7 – 8.3) and moderate stunting 15.5% (95% CI: 12.5 – 19.1) in 2011.

The overall prevalence of underweight in Hagadera has decreased from 28.0% in the 2011nutrition survey to 18.3% this year, as seen in the table below. Prevalence of both moderate andsevere categories of underweight saw a non-significant decrease from the levels seen in 2011.


Table 22 Prevalence of underweight based on weight-for-age z-scores by sex-Hagadera camp, Dadaab(Oct 2012)

Alln = 591

Boysn = 298

Girlsn = 293

Prevalence of underweight(<-2 z-score)

n = 10818.3%

(15.1 – 22.0)

n = 6220.8%

(16.3 – 26.3)

n = 4615.7%

(11.5 – 21.0)Prevalence of moderateunderweight(<-2 z-score and >=-3 z-score)

n = 8213.9%

(11.4 – 16.8)

n = 5016.8%

(13.5 – 20.7)

n = 3210.9%

(7.6 – 15.5)Prevalence of severeunderweight (<-3 z-score)

n = 264.4%

(3.0 – 6.5)

n = 124.0%

(2.1 – 7.7)

n = 144.8%

(2.8 – 8.0)

Table 23 Mean z-scores, Design Effects and excluded subjects - Hagadera camp, Dadaab (Oct 2012)

Indicatorn Mean z-scores

± SDDesign Effect(z-score < -2)

z-scores notavailable*

z-scores out ofrange

Weight-for-Height 594 -0.66 ± 1.13 1.00 6 3Weight-for-Age 591 -1.10 ± 1.04 1.12 3 6Height-for-Age 576 -1.16 ± 1.19 2.35 3 21

* For WHZ and WAZ this figure includes children with oedema.

MUAC is being used in the community for screening and admission to therapeutic andsupplementary feeding programmes as it is a good indicator of risk of mortality in children under 5and is easy to do. As seen by Table 24, there is no useful agreement between MUAC-basedestimates of acute malnutrition and GAM and SAM determined by weight-for-height.

Table 24 Prevalence of malnutrition based on MUAC (N=600) - Hagadera camp, Dadaab (Oct 2012)

Malnutrition CategoryNumber of cases,

prevalence and 95% CI

Prevalence of global malnutrition(< 125 mm and/or oedema)

n=233.8 %

(2.4 - 6.1)

Prevalence of moderate malnutrition(< 125 mm and >= 115 mm, no oedema)

n=183.0 %

(1.7 - 5.1)

Prevalence of severe malnutrition(< 115 mm and/or oedema)

n=50.8 %

(0.3 - 2.3)

The caseloads for the selective feeding programmes were estimated to aid in future programmeplanning. The total population estimate for Hagadera used during the survey was 138,942 (basedon UNHCR ProGres data). The total population of the surveyed households and the proportionthat were under 5 years of age was calculated from the household listing forms (and householdquestionnaires). It was found that approximately 25.8% of the surveyed population in Hagaderawas under-5 years, which was equivalent to 35,847 infants and children in the whole ofHagadera. It was assumed that 10% of under-fives were 0-5 months, so it could be estimatedthat 32,262 children were 6-59 months. This figure was then multiplied by the estimatedproportion of children eligible to be enrolled in either TFP or TSFP for Hagadera to give theestimated caseload.


Table 25 Estimated number of malnourished children aged 6-59 months eligible to be enrolled in acutemalnutrition treatment feeding programmes (case load) at the time of the survey (based on all admissioncriteria) - Hagadera camp, Dadaab (Oct 2012)

Prevalence% (95% CI)*

Total estimatedcaseload

Eligible for Therapeutic FeedingProgramme**

3.4%(1.8 – 4.9)

1,097

Eligible for TargetedSupplementary FeedingProgramme**

8.5%(5.8 – 11.2)

2,904

*WHZ flags excluded from analysis

Anaemia results

Table 26 Prevalence of anaemia and haemoglobin concentration in children 6-59 months of age -Hagadera camp, Dadaab (Oct 2012) (n = 600)

Anaemia CategoriesNumber of cases

Prevalence(95% CI)

Total Anaemia (Hb<11.0 g/dL)n = 26744.5%

(39.2 – 50.0)

Mild Anaemia (Hb 10.0-10.9 g/dL)n = 13823.0%

(19.4 – 26.6)

Moderate Anaemia (7.0-9.9 g/dL)n = 12520.8%

(16.8 – 24.8)

Severe Anaemia (<7.0 g/dL)n = 40.7%

(0.0 – 1.3)

Mean Hb10.9 g/dL

(5.5 – 14.5)

Comparison with results from 2011 shows that the levels of anaemia remain stable. No change isseen between the prevalence this year, 44.5% (95% 39.2 - 50.0), and total anaemia in 2011,45.3% (95% 40.4-50.2).

Figure 7 Nutrition survey results (anaemia in children 6-59 months) since 2009 - Hagadera camp, Dadaab(Oct 2012)


As expected, for every category of anaemia (severe, moderate or mild) the age group mostaffected by anaemia is the youngest children between 6 – 23 months, confirming them as themost vulnerable group.

Table 27 Prevalence of anaemia by age - Hagadera camp, Dadaab (Oct 2012)

Severe Anaemia(<7.0 g/dL)

Moderate Anaemia(7.0-9.9 g/dL)

Mild Anaemia (Hb10.0-10.9 g/dL)

Total Anaemia(Hb<11g.0

g/dL)

Normal(Hb≥11.0 g/dL)

Age(mon)

Totalno.

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

6-23 205 3 1.5%(0 – 3.1)

72 35.1%(26.8 – 43.4)

55 26.8%(20.1 – 33.6)

130 63.4%(55.1 –71.7)

75 36.6%(28.3 –44.9)

24-35 150 1 0.7%(0.0 – 2.0)

36 24.0%(16.4 – 31.6)

32 21.3%(15.9 – 26.7)

69 46.0%(36.9 –55.1)

81 54.0%(44.9 –63.1)

36-59 245 0 0.0-

17 6.9%(3.5 – 10.4)

51 20.8%(14.9 – 26.7)

68 27.8%(22.4 –33.1)

177 72.2%(66.9 –77.6)

Total 600 4 0.7%(0.0 – 1.3)

125 20.8%(16.8 – 24.8)

138 23.0%(19.4 – 26.6)

267 44.5%(39.2 –50.0)

333 55.5%(50.1 –60.9)

Figure 8 below shows trends in anaemia prevalence since 2009, in children aged 6-23. This canbe useful to assess the impact of the special nutritional product used (CSB++ used since surveyin 2011) to help reduce anaemia in children 6-23 months.

Figure 8 Anaemia in children 6-23 months, since 2009-Hagadera camp, Dadaab (Oct 2012)


Programme coverage

Selective feeding programmes

Table 28 Acute malnutrition treatment programme coverage based on all admission criteria (weight-for-height, MUAC, oedema) - Hagadera camp, Dadaab (Oct 2012)

Number/total % (95% CI)Proportion of children aged 6-59 months with Severe AcuteMalnutrition currently enrolled in Therapeutic Feeding Programme* 1 / 19

5.3%(0.7 – 31.4%)

Proportion of children aged 6-59 months with Moderate AcuteMalnutrition currently enrolled in Targeted Supplementary FeedingProgramme*

5 / 519.8%

(2.8 – 29.1)

*WHZ flags excluded in analysis

Table 29 Acute malnutrition treatment programme coverage based on MUAC and oedema admissioncriteria only - Hagadera camp, Dadaab (Oct 2012)

Number/total % (95% CI)

Proportion of children aged 6-59 months with Severe AcuteMalnutrition currently enrolled in Therapeutic Feeding Programme

0 / 40.0-

Proportion of children aged 6-59 months with Moderate AcuteMalnutrition currently enrolled in Targeted Supplementary FeedingProgramme

6 / 2326.1%

(8.5 – 57.1)

Blanket Supplementary Feeding Programme (BSFP)

The coverage of the Blanket Supplementary Feeding Programme (BSFP) is shown in the tablebelow and this year was extremely low. The coverage of BSFP in 2011 was 48.9% (95% CI 39.5- 58.3) (Nutributter® was distributed to children 6-23 months until August 2011, when it wasreplaced by CSB++).

Table 30 CSB++ Distribution (BSFP programme) for children aged 6-23 months - Hagadera camp, Dadaab(Oct 2012)


Currently receiving CSB++ 13 / 2046.4%

(2.4 – 10.3)

Vaccination and supplementation programmes

Measles vaccination coverage

Following the outbreak of measles in the first half of 2012, it is important to know the measlesvaccination coverage, as there had been no mass measles vaccination campaign since early in2011.

Table 31 Measles vaccination coverage for children aged 9-59 months (n=572) - Hagadera camp, Dadaab(Oct 2012)

Measles Vaccination(with card confirmation)

n= 291

Measles Vaccination(with card or confirmation from mother)

n=56050.9%

(36.7 – 65.0)97.9 %

(96.0 – 99.8)


PENTA vaccination coverage

PENTA vaccination coverage was measured in light of a potential outbreak of pertussis(whooping cough).

Table 32 PENTA vaccination coverage for children aged 6-59 months (n= 600) - Hagadera camp, Dadaab(Oct 2012)

PENTA 1 (only)n= 0

PENTA 2n=14

PENTA 3n= 491

Vaccination(with card

confirmation)

0.0 %( - )

2.3 %(0.0 - 4.7)

81.8%(70.4 – 93.3)

Vitamin A supplementation coverageVitamin A supplementation was a focus of the Malezi Bora campaign in May 2012 and it istherefore expected that even if not recorded on the child’s card, the caregiver could recall if thechild received it or not.

Table 33 Vitamin A supplementation (n=600) for children aged 6-59 months

Vitamin A capsule received(with card confirmation)

n=242

Vitamin A capsule received(with card confirmation or from mother’s recall)

n=57840.3%

(25.4 – 55.3)96.3 %

(91.8 – 100.0)

The coverage of Vitamin A supplementation confirmed by card almost doubled from the 2011nutrition survey (20.9%, 95% CI: 13.6 - 28.2). Levels of vitamin A supplementation by either cardor recall also increased from the 2011 value (86.8%, 95% CI: 82.1 - 91.5).

Figure 9 Nutrition survey results: vitamin A supplementation within past 6 months with card) since 2010 -Hagadera camp, Dadaab (Oct 2012)


Figure 10 Measles vaccination coverage trends since August 2010 – Hagadera camp, Dadaab (Oct 2012)

Deworming coverage

Table 34 Deworming for children aged 24-59 months within past 6 months (n = 395) - Hagadera camp,Dadaab (Oct 2011)

Dewormed % (95% CI)

379 / 39595.9%

(91.1 – 100.0%)

Deworming of children aged 24 – 59 months was measured by recall only. Compared with resultsfrom 2011, the coverage of deworming within the past 6 months has significantly increased (from81.7%, 95% CI: 74.9 - 88.5) in 2011, (p<0.05).

Figure 11 Nutrition survey results (deworming for children aged 24-59 months within past 6 months) since2010 – Hagadera camp, Dadaab (Oct 2012)


The prevalence of reported diarrhoea in Hagadera was very low in the two weeks leading up tothe survey, as seen in Table 35.

Morbidity from diarrhoea and feeding during diarrhoea

Table 35 Prevalence of reported diarrhoea in the two weeks prior to the interview - Hagadera camp,Dadaab (Oct 2012)


Diarrhoea in past 2 weeks 5 / 5990.8%

(0.1 – 1.5)

Below in Table 36, three of the five children having diarrhoea in the past two weeks were fed nofood and one was fed less than normal.

Table 36 Feeding during diarrhoea episodes - Hagadera camp, Dadaab (Oct 2012)

Feeding Practices Cases (N = 5)*

Less than normal n = 1Same as normal n = 1More than normal n = 0No food n = 3

*Proportions and 95% CI are not given due to the low number of responses to this question.

CHILDREN 0-23 MONTHS - HAGADERA CAMP, DADAAB (Oct 2012)

Demographic information of children 0 – 23 months is consistent with the demographic data ofchildren 6 – 59 months.



Somali 251 / 320 78.4%Somali Bantu 69 / 320 21.6%Others 0 / 320 -

Arrival in camp<3 months 2 / 320 0.6%3-6 months 2 / 320 0.6%9-12 months 1 / 320 0.3%Before October 2011 315 / 320 98.4%

Results of the IYCF questionnaire are summarised in the table below, which includes theresponses for four of the WHO core Indicators and three optional indicators for IYCF, plus theprovision of other fluids to children, and feeding practices during diarrhoea in infants.


Table 38 Prevalence of Infant and Young Child Feeding Practices indicators - Hagadera camp, Dadaab(Oct 2012)

Indicator Age range n / total Prevalence (%) 95% CI

Children ever breastfed 0-23 m 299 / 320 93.4% 89.0 – 97.8

Early initiation of breastfeeding 0-23 m 287 / 299 96.0% 91.9 – 100.0

Exclusive breastfeeding under 6 months 0-5 m 93 / 112 83.0% 73.4 – 92.6

Continued breastfeeding at 1 year 12-15 m 26 / 41 63.4% 45.3 – 81.5

Continued breastfeeding at 2 years 20-23 m 8 / 35 22.9% 5.7 – 40.0

Introduction of solid, semi-solid, soft foods 6-8 m 20 / 30 66.7% 45.7 – 87.6

Children bottle fed 0-23 m 10 / 320 3.1% 0.2 – 6.0

Children given infant formula 0-23 m 6 / 320 1.9% 0.0 – 3.8

Children given milk or milk alternative 0-12 m 39 / 181 21.5% 14.6 – 28.5

Children given Tea/coffee 0-23 m 111 / 320 34.7% 26.4 – 42.9

Children given water or sugar water 0-6 m 19 / 114 16.7% 7.2 – 26.2

Reported prevalence of diarrhoea 0-23 m 15 / 320 4.7% 2.0 – 7.3

Continued feeding during diarrhoea 0-23 m 7 / 15 46.7% 7.2 – 86.2

By noting the confidence intervals it can be seen that some indicators have improved since theprevious survey in 2011; early initiation of breastfeeding and exclusive breastfeeding under 6months. Other indicators appear to have decreased; namely children ever breastfed. The clearestchanges in IYCF indicators for Hagadera, is the jump in exclusively breastfed infants under 6months.

Figure 12 Nutrition survey results (key IYCF indicators) since 2009 - Hagadera camp, Dadaab (Oct 2012)

WOMEN 15-49 YEARS-HAGADERA CAMP, DADAAB (Oct 2012)

As expected, the demographic data of women 15 – 49 years is similar to that of the surveyedchildren and infants.

Table 39 Demographic profile of survey sample - Hagadera camp, Dadaab (Oct 2012)


Somali 245 / 306 80.1Somali Bantu 61 / 306 19.9Others 0 / 306 0.0

Arrival in camp


<3 months 0 / 306 0.03-6 months 2 / 306 0.7Pre October 2011 (>12 months) 304 / 306 99.3

Physiological statusPregnant 25 / 306 8.2Lactating (until 6 months post-natal 72 / 306 23.5Neither lactating nor pregnant 209 / 306 68.3

Age of WomenMean Age 26.6 years (25.8 – 27.5)

As seen in the table below, the prevalence of anaemia amongst non-pregnant women (15 – 49years) was similar to 2011 (43.3%; 95% CI: 35.6 - 50.9).

Table 40 Prevalence of anaemia in non-pregnant women of reproductive age (15-49 years) - Hagaderacamp, Dadaab (Oct 2012) (n = 281)


Prevalence(95% CI)

Total Anaemia (<12.0 g/dL)n=10938.8%

(30.9 - 46.7)

Mild Anaemia (11.0-11.9 g/dL)n=51

18.1%(12.9 - 23.4)

Moderate Anaemia (8.0-10.9 g/dL)n=55

19.6%(12.9 - 26.2)

Severe Anaemia (<8.0 g/dL)n=3

1.1%(0.0 - 2.3)

Mean Hb (g/dL)12.2 g/dL(7.4 -16.4)

Figure 13 below shows a decreasing trend in the prevalence of anaemia, while the proportion ofanaemia in each category has remained about the same as in the 2011 survey.


Figure 13 Nutrition survey results (anaemia) since 2009-Hagadera camp, Dadaab (Oct 2012)

ANC enrolment and iron-folic acid supplementation coverage

Enrolment in ANC programme and coverage of iron-folic acid supplement is very high and thenumber of women able to present their enrolment card was also high, as seen in Table 41.

Table 41 ANC enrolment and iron-folic acid pills coverage among pregnant women (15-49 years) -Hagadera camp, Dadaab (Oct 2012)


Currently enrolled in ANC programmewith card confirmation

24 / 2596.0%

(87.5 – 100.0)

Currently enrolled in ANC programmewith card confirmation or recall

25 / 25100.0%

-

Currently receiving iron-folic acid pills 24 / 2596.0%

(87.5 – 100.0)

The coverage of post-natal Vitamin A supplementation for women in Hagadera was good. It wasmuch higher than in 2011, as seen in Figure 14 below.

Table 42 Post-natal vitamin A supplementation among women (15-49 years) - Hagadera camp, Dadaab(Oct 2012)


Received vitamin A supplementation since deliverywith card

N = 33 / 7245.8%

(27.3 – 64.3)

Received vitamin A supplementation since deliverywith card or recall

N = 67 / 7293.1%

(87.4 – 98.7)


Figure 14 Trends in coverage of ANC programmes, Hagadera (2012)

HOUSEHOLD-LEVEL INDICATORS - WASH AND FOOD SECURITY-HAGADERA CAMP, DADAAB (OCT 2012)

Table 43 shows the target sample size and actual number of households sampled for householdlevel indicators in Hagadera camp. All households were included whether or not they had eligibleindividuals for the individual-level questionnaires.

Table 43 Target sample size and actual number captured during the survey-Hagadera camp, Dadaab (Oct2012)

IndicatorTarget

sample size

Householdsinterviewed during

the study% of the target

WASH / Food Security 360 359 99.7%

In Hagadera, households arriving in the camp within the last 12 months represented 2.2% of thesample for the Household questionnaire (Food Security and WASH). The number of householdshosting recent arrivals was 19 of 359 (5.3%).


Number/total %Date of arrival of household in camp

<3 months 1 0.3%3-6 months 4 1.1%6-9 months 2 0.6%9-12 months 1 0.3%>12 months 351 97.8%



Number/totalAverage HH size 6.5 persons

Of 359 HH interviewed, the smallest HH was 2 persons and largest was 20 persons.

Figure 15 Household size – Hagadera Camp, Dadaab (Oct 2012)

FOOD SECURITY - HAGADERA CAMP, DADAAB (OCT 2012)The majority of households surveyed reported that their ration lasted less than the 15 day rationdistribution cycle. The least number of days the ration lasted was 2 and the highest was 17 days.

Table 46 Ration card coverage and duration of general food ration - Hagadera camp, Dadaab (Oct 2012)


Proportion of households with a ration card 357 / 35999.4 %

(98.7 – 100.0)Proportion of surveyed HH who had one or moremembers that were not registered on the ration card

24 / 357 6.7%

Proportion of households reporting that the GFRlasted <15 days

222 / 35961.8%

(53.1 – 70.6)

Table 47 Duration that GFR lasts in Households - Hagadera Camp, Dadaab (Oct 2012)

Number days 95% CI

Average number of days GFR lasts 12.6 12.1 – 13.1

Two households reported not being given a ration card at registration. These two households hadboth arrived recently (within past 6 months), and therefore may have not been registered due tothe Government of Kenya restricting the registration process.

The 222 households who reported that the GFR did not last the entire cycle were asked why thiswas. The main reason given was that some food was sold or exchanged (n = 128), followed bythe ration not being big enough (n=54). Some reported ‘scooping / other’ as the reason (n=30),and only a few answered that it was shared with kin (n=5) or because new arrivals had joined(n=5).


Figure 16 Main reason given by households (n=222) for why the general food ration did not last until thenext distribution - Hagadera camp, Dadaab (Oct 2012)

As shown in Figure 17 below, the most important coping strategy that was reported to fill the foodgap was to borrow or receive credit from family, friends, or neighbours.

Figure 17 Coping strategies used by households (n=222) to fill the food gap when general food ration runsout - Hagadera camp, Dadaab (Oct 2012)

Table 48 below indicated that almost half of the households sold or exchanged part of the GFR. Itwas predominantly sold or exchanged for meat, sugar and milk seen by Figure 18.


Table 48 Sale or exchange of food from general ration - Hagadera camp, Dadaab (Oct 2012)

Number/total %

Proportion of households selling orexchanging food ration items

n = 170 / 359 47.4%

Figure 18 Most common items bought when general ration is sold or exchanged - Hagadera camp,Dadaab (Oct 2012)

Barriers relating to insecurity

Has insecurity or closure of health centres prevented anyone in your household fromvisiting a health centre in the last 2 months?

8 / 356 households responded ’yes’ (2.2%) 3 responded that they did not need to go

Has insecurity prevented anyone in your household from collecting the GFD in the last 2 months?

8 / 359 households responded ‘yes’ (2.2%)

WATER, SANITATION AND HYGIENE - HAGADERA CAMP, DADAAB (OCT 2012)

Whether a household had enough water containers to collect adequate water for the household isshown in Table 49 below.

Table 49 Ownership of adequate water containers - Hagadera camp, Dadaab (Oct 2012)

Number/total % (95% CI)Proportion of households that say they haveenough water containers to collect water

263 / 35973.3%

(62.8 – 87.7)

All but one household surveyed collected drinking water from a public tap / standpoint. The onehousehold that reportedly collected water from a UNHCR tanker may have been a data recordingerror, as it is unlikely that only one household would collect water from this source taking intoconsideration the geographical spread of the second stage sampling.


Table 50 Proportion of HH using an improved drinking water source – Hagadera camp, Dadaab (Oct 2012)

Source Number / Total % (95%CI)

Public Tap / Standpipe 358 / 35999.7%

(99.2 – 100.0)

UNHCR tanker 1 / 3590.3%

(0.0 – 0.8)

The majority of households are satisfied with the water supply in Hagadera, however somehouseholds stated they were not happy and cited the main reason below in Table 51.

Table 51 Satisfaction with water supply - Hagadera camp, Dadaab (Oct 2012)

Number/total % (95% CI)Proportion of households that say they are satisfiedwith the drinking water supply

306 / 35985.2%

(76.6 – 93.8)

Reasons for not being satisfied with water supply; N = 17 (amount is not enough) N = 30 (long queues) N = 6 (water point is far)

A vast improvement in distribution of soap has been seen from 2011, when the proportion ofhouseholds receiving soap was just 2.0%.

Table 52 Soap distribution - Hagadera camp, Dadaab (Oct 2012)

Number/total % (95% CI)Proportion of households that received soap during the lasttwo distribution cycles or at reception

353 / 35898.6%

(96.8 – 100.0)

With a significant population being hosted in Hagadera, the number of families sharing toilets hasincreased since the 2011 nutrition survey. More than one third, 36.6% (95% CI 27.4-48.4) ofhouseholds used an improved excreta disposal facility that wasn’t shared, and 31.6% (95% CI18.7 – 44.4) used an unimproved toilet.

Table 53 Safe Excreta disposal - Hagadera camp, Dadaab (Oct 2012)

Excreta disposal methods Number/total % (95% CI)Proportion of households using an improved excretadisposal facility 131 / 358

36.6%(27.4 – 48.4)

Proportion of households using a shared family toilet.62 / 358

17.3%(10.3 – 24.4)

Proportion of households using a communal toilet52 / 358

14.5%(7.4 – 21.6)

Proportion of households using an unimproved toilet113 / 358

31.6%(18.7 – 44.4)

Having three or more households sharing a toilet may be a contributing factor to the spread ofdisease should such an outbreak occur in Hagadera. 18.8% of households share a toiletbetween three or more households.

Table 54 Sharing of Toilet Facilities - Hagadera camp, Dadaab (Oct 2012)

Sharing of Toilet Facilities Number / Total % (95% CI)

One HH uses facility 196 / 34057.6%

(48.0 – 67.3)

Two HHs use facility 80 / 34023.5%

(16.7 – 30.3)

Three or more HHs use facility 64 / 34018.8%

(3.7 – 11.3)


RESULTS FROM IFO-2 CAMP, DADAAB (SEPT 2012)

INDIVIDUAL-LEVEL INDICATORS;CHILDREN 6-59 MONTHS,INFANTS AND YOUNG CHILDREN 0-23 MONTHS,WOMEN OF REPRODUCTIVE AGE 15-49 YEARS

HOUSEHOLD INDICATORS: WASH AND FOOD SECURITY

Table 55 provides the planned sample size and the actual sample achieved during the survey foreach target population group. Thirty clusters were sampled for all indicators, therefore thenumber of required records per cluster varied according to the total target sample size required.

Table 55 Target sample size and actual number sampled during the survey - Ifo-2 camp, Dadaab (Sept2012)



during the survey

% of the target

Children 6-59 months 600 630 105%


Women 15-49 years 300 333 111%

CHILDREN 6-59 MONTHS - IFO-2 CAMP, DADAAB (OCT 2012)

Outlined below in Table 56 is the demographic data of children surveyed: nationality, time ofarrival to Dadaab and the region of origin if recently arrived (i.e. within past 12 months)

Table 56 Demographic information - Ifo-2 camp, Dadaab (Sept 2012)


Somali 553 / 630 87.8%Somali Bantu 77 / 630 12.2%Others 0 / 630 0.0

Arrival in camp<3 months 0 / 630 0.03-6 months 5 / 630 0.8%6-9 months 3 / 630 0.5%9-12 months 3 / 630 0.5%>12 months 619 / 630 98.3%

Region of origin forchildren in camp for<12 months

Lower Juba 5 / 11 45.5%Middle Juba - -Gedo - -Bay - -Bakool 3 / 11 27.3%Lower Shabelle - -Middle Shabelle - -Hiraan - -Mogadishu/Banadir 3 / 11 27.3%Other - -


Anthropometric results (based on WHO Growth Standards 2006)

The coverage of age documentation was average with 51% of children having an exact birthdate. The oldest age group (54-59) was slightly under represented, and children 30-41 montholds had slightly more children than all other age groups.

Table 57 Distribution of age and sex of sample - Ifo-2 camp, Dadaab (Sept 2012)

Boys Girls Total RatioAGE (mo) no. % no. % no. % Boy:girl6-17 65 50.0 65 50.0 130 20.6 1.018-29 73 51.8 68 48.2 141 22.4 1.130-41 76 49.7 77 50.3 153 24.3 1.042-53 66 50.4 65 49.6 131 20.8 1.054-59 45 60.0 30 40.0 75 11.9 1.5Total 325 51.6 305 48.4 630 100.0 1.1

There was equal number of boys and girls represented in the survey in Ifo-2, shown by the sex-ratio of 1.07 (within the accepted range of 0.8 – 1.2).

Table 58 Prevalence of acute malnutrition based on weight-for-height z-scores(and/or oedema)* and by sex - Ifo-2 camp, Dadaab (Sept 2012)

Alln = 622

Boysn = 320

Girlsn = 302


n = 9315.0%

(12.3 – 18.0)

n = 5216.3%

(12.8 – 20.4)

n = 4113.6%

(9.5 – 19.0)

Prevalence of moderate malnutrition(<-2 z-score and >=-3 z-score, nooedema)

n = 619.8%

(7.8 – 12.2)

n = 3711.6%

(8.5 – 15.6)

n = 247.9%

(5.2 – 12.0)

Prevalence of severe malnutrition(<-3 z-score and/or oedema)

n = 325.1%

(3.7 – 7.1)

n = 154.7%

(3.0 – 7.2)

n = 175.6%

(3.3 – 9.5)

*The prevalence of oedema was 0.8 % (n=5)

Ifo-2 is a new camp, opened since the 2011 survey; therefore no trend comparison can be madefor the prevalence of acute malnutrition.

Table 59 Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema -Ifo-2 camp, Dadaab (Sept 2012)


Moderate wasting(>= -3 and <-2 z-

score )


Oedema

Age (mo) Totalno.

No. % No. % No. % No. %

6-17 127 15 11.8 20 15.7 90 70.9 2 1.6

18-29 138 4 2.9 12 8.7 122 88.4 1 0.7

30-41 152 2 1.3 8 5.3 140 92.1 1 0.7

42-53 130 2 1.5 11 8.5 117 90.0 0 0.0

54-59 75 4 5.3 10 13.3 60 80.0 1 1.3

Total 622 27 4.3 61 9.8 529 85.0 5 0.8

The highest proportion of severe and moderate wasting (and total GAM) occurs in the youngestchildren, aged 6 – 17 months. Surprisingly the oldest, children 54 – 59 months, are the next mostaffected group, as in Hagadera.


Figure 19 Trends in the prevalence of wasting by age in children 6-59 months - Ifo-2 camp, Dadaab (Sept2012)

Table 60 below, shows that when children are affected by nutritional oedema they usually have aweight-for-height z-score >-3. All cases of oedema are classified as Kwashiorkor as their weightis increased by accumulating extra fluid.

Table 60 Distribution of severe acute malnutrition and oedema based on weight-for-height z-scores - Ifo-2camp, Dadaab (Sept 2012)

<-3 z-score >=-3 z-score

Oedema presentMarasmic kwashiorkor

N = 0Kwashiorkor

N = 5

Oedema absentMarasmic


N = 593

Figure 20 shows that the weight-for-height z-score distribution is shifted to the left, illustrating apoorer nutritional status than the international WHO Standard (2006) population of children aged6-59 months.

Figure 20 Distribution of weight-for-height z-scores (based on WHO Growth Standards; the referencepopulation is shown in green) of survey population compared to reference population - Ifo-2 camp, Dadaab(Sept 2012)


The very high prevalence of stunting in Ifo-2 (i.e. >40% stunting) indicates the situation is critical,and suggests that children have experienced prolonged periods of malnutrition in their earlyyears.

Table 61 Prevalence of stunting based on height-for-age z-scores and by sex - Ifo-2 camp, Dadaab (Sept2012)

Alln = 597

Boysn = 291

Girlsn = 285


n = 24941.7%

(37.3 – 46.3)

n = 13242.7%

(37.2 – 48.4)

n = 11740.6%

(34.8 – 46.7)Prevalence of moderate stunting(<-2 z-score and >=-3 z-score)

n = 13622.8%

(19.9 – 25.9)

n = 6922.3%

(18.4 – 26.8)

n = 6723.3%


n = 11318.9%

(15.3 – 23.2)

n = 6320.4%

(15.7 – 26.0)

n = 5017.4%

(13.0 – 22.8)

Children in the age groups 18-29 and 6-17 months in Ifo-2 are the most affected by stunting as comparedto the other age groups, seen by the proportions by age group in the table below.

Table 62 Prevalence of stunting by age based on height-for-age z-scores - Ifo-2 camp, Dadaab (Sept2012)


Moderatestunting

(>= -3 and <-2 z-score )


Age(mo)

Totalno.

No. % No. % No. %

6-17 122 17 13.9 37 30.3 69 56.6

18-29 133 33 24.8 34 25.6 66 49.6

30-41 146 36 24.7 24 16.4 86 58.9

42-53 124 21 16.9 31 25.0 72 58.1

54-59 72 7 9.7 10 13.9 55 76.4

Total 597 113 18.9 136 22.8 348 58.3

Figure 21 Trends in the prevalence of stunting by age in children 6-59 months - Ifo-2 camp, Dadaab (Sept2012)


Table 63 Prevalence of underweight based on weight-for-age z-scores by sex - Ifo-2 camp, Dadaab (Sept2012)

Alln = 615

Boysn = 317

Girlsn = 298


n = 20032.5%

(28.5 – 36.8)

n = 10232.2%

(25.5 – 39.7%)

n = 9832.9%


n = 13121.3%

(18.3 – 24.6)

n = 6921.8%

(16.7 – 27.8)

n = 6220.8%

(16.5 – 25.8)Prevalence of severe underweight(<-3 z-score)

n = 6911.2%

(8.7 – 14.3)

n = 3310.4%

(7.0 – 15.1)

n = 3612.1%

(8.8 – 16.3)

The mean z-scores for each nutritional index (see below) was negative, indicating that thenutritional status is poor in Ifo-2. The standard deviations for weigh-for-height and weight-for-agewere acceptable; however the SD for height-for-age was a little higher.

Table 64 Mean z-scores, Design Effects and excluded subjects - Ifo-2 camp, Dadaab (Sept 2012)

Indicator n Mean z-scores± SD

Design Effect(z-score < -2)



Weight-for-Height 617 -0.84±1.17 1.00 6 7

Weight-for-Age 615 -1.56±1.09 1.17 5 10

Height-for-Age 597 -1.74±1.34 1.19 0 33

* contains children with disability and height not able to be measured for WHZ and children with oedemafor WHZ and WAZ.

MUAC is being used in the community for screening and admission to therapeutic andsupplementary feeding programmes as it is a good indicator of risk of mortality in children under 5and is easy to do. As seen again from the MUAC results in the table below, no useful agreementis found between MUAC-based malnutrition estimates and estimates determined using weight-for-height.


Table 65 Prevalence of malnutrition based on MUAC (N=630) - Ifo-2 camp, Dadaab (Sept 2012)



Prevalence of global malnutrition(< 125 mm and/or oedema)

n=579.0 %

(7.0 -11.6)

Prevalence of moderate malnutrition(< 125 mm and >= 115 mm, no oedema)

n=365.7 %

(4.0 - 8.1)

Prevalence of severe malnutrition(< 115 mm and/or oedema)

n=213.3 %

(2.0 - 5.5)

The caseloads for the selective feeding programmes were estimated to aid in future programmeplanning. The total population estimate for Ifo-2 used during the survey was 69,091 (based onUNHCR ProGres data). The total population of the surveyed households and the proportion thatwere under 5 years of age was calculated from the household listing forms (and householdquestionnaires). It was found that approximately 27.7% of the surveyed population in Ifo-2 wasunder-5 years, which was equivalent to 19,138 infants and children in the whole of Ifo-2. It wasassumed that 10% of under-fives were 0-5 months, so it could be estimated that 17,224 childrenwere 6-59 months. This figure was then multiplied by the estimated proportion of children eligibleto be enrolled in either TFP or TSFP for Ifo-2 to give the estimated caseload.

Table 66 Estimated number of malnourished children aged 6-59 months eligible to be enrolled in aselective feeding programme at the time of the survey (based on all admission criteria) - Ifo-2 camp,Dadaab (Sept 2012)



Eligible for Therapeutic FeedingProgramme*

6.2%(4.0 – 8.3)

1,067

Eligible for TargetedSupplementary FeedingProgramme*

12.1%(9.7 – 14.4)

2,084


Anaemia results

The prevalence of anaemia (45.5%; 95% 40.9-50.1) (see table below) is comparable to the othercamps and is quite encouraging considering the higher rate of malnutrition, stunting, underweightand also prevalence of diarrhoea of children in Ifo-2.

Table 67 Prevalence of anaemia and haemoglobin concentration in children 6-59 months of age - Ifo-2camp, Dadaab (Sept 2012) (n = 629)


Prevalence(95% CI)


(40.9 – 50.1)


(25.5 – 32.0)


(13.2 – 19.5)



(0.0 – 0.8)

Mean Hb (g/dL)11.1 g/dL

(Range 6.0 – 14.8)

Again, children 6-23 months showed the highest proportion of each category of anaemia (severe,moderate and mild) in Ifo-2 camp as outlined in Table 68 below.

Table 68 Prevalence of anaemia by age - Ifo-2 camp, Dadaab (Sept 2012)

Severe Anaemia(<7.0 g/dL)

Moderate Anaemia(7.0-9.9 g/dL)

Mild Anaemia (Hb10.0-10.9 g/dL)

Total Anaemia(Hb<11g.0 g/dL)

Normal (Hb≥11.0 g/dL)

Age(mon)

Totalno.

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

6-23 183 10.5%

(0.0 – 1.7)50

27.3%(21.2 – 33.5)

6535.5%

(30.8 – 40.3)116

63.4%(57.1 – 69.7)

6736.6%

(30.3 – 42.9)

24-35 126 10.8%

(0.0 – 2.4)25

19.8%(12.3 – 27.4)

4132.5%

(24.4 – 40.7)67

53.2%(42.3 – 64.1)

5946.8%

(35.9 – 57.7)

36-59 320 00.0%

-28

8.8%(6.0 – 11.5)

7523.4%

(18.9 – 28.0)103

32.2%(27.2 – 37.1)

21767.8%

(62.9 – 72.8)

Total 629 20.3%

(0.0 – 0.8)103

16.4%(13.2 – 19.5)

18128.8%

(25.5 – 32.0)286

45.5%(40.9 – 50.1)

34354.5%

(49.9 – 59.1)

Programme coverage

Selective feeding programmes

Considering the UNHCR and globally agreed target for programme coverage for TFP andtargeted SFP is >90%, the coverage in Ifo-2 by all admission criteria is very low.

Table 69 Nutrition treatment programme coverage based on all admission criteria (weight-for-height,MUAC, oedema) - Ifo-2 camp, Dadaab (Sept 2012)


Proportion of children aged 6-59 months with severe acutemalnutrition currently enrolled in therapeutic feeding programme*

18 / 3946.2%

(32.4 – 60.0)

Proportion of children aged 6-59 months with moderate acutemalnutrition currently enrolled in supplementary feeding programme*

13 / 7617.1%

(9.7 – 28.4)

*WHZ flags excluded

The coverage calculated for nutrition programmes when using MUAC and oedema criteria onlyfor admission is also unacceptably low.

Table 70 Nutrition treatment programme coverage based on MUAC and oedema only - Ifo-2 camp,Dadaab (Sept 2012)


Proportion of children aged 6-59 months with severe acutemalnutrition currently enrolled in therapeutic feeding programme

13 / 2161.9%

(36.0 – 82.4)Proportion of children aged 6-59 months with moderate acutemalnutrition currently enrolled in supplementary feeding programme

13 / 3636.1%

(20.9 – 54.7)


Measles vaccination coverageFollowing the outbreak of measles in the first half of 2012, it is particularly important to know themeasles vaccination coverage, as there had been no mass measles vaccination for Ifo-2 since it


has been constructed and refugees relocated there. It was therefore expected that thevaccination coverage might be lower in Ifo-2 and the data shows that this is indeed the case, withvery low coverage found when card confirmation is required. When confirmation by card or recallis accepted the coverage still fails to reach the target or 95%.

Table 71 Measles vaccination coverage for children aged 9-59 months (n=596) - Ifo-2 camp, Dadaab (Sept2012)


n= 133


n=49722.3%

(16.3 – 29.8)83.4%

(70.1 – 91.5)

PENTA vaccination coveragePENTA vaccination coverage was measured during the survey in light of a potential outbreak ofpertussis (whooping cough) in the camps.

Table 72 PENTA vaccination coverage for children aged 6-59 months (n=630) - Ifo-2 camp, Dadaab (Sept2012)

PENTA 1 (only)n= 26

PENTA 2n=93

PENTA 3n= 365


confirmation)

4.1%(1.7 – 9.6)

14.8%(8.2 – 25.1)

57.9%(45.3 – 69.6)

The remaining 23.2% of children 6 – 59 months (n=146) had not received any PENTA doses.

Vitamin A supplementation coverageVitamin A supplementation was a focus of the Malezi Bora campaign in May 2012 and it istherefore expected that even if not recorded on the child’s card, that the caregiver could recallwhether the child received it or not.

Table 73 Vitamin A supplementation for children aged 6-59 months within past 6 months (n=630) - Ifo-2camp, Dadaab (Sept 2012)


n= 146

Vitamin A capsule received(with card confirmation or from

mother’s recall)n=617

23.2%(15.6 – 32.9)

97.9%(95.1 – 99.1)

Deworming coverageAs with Vitamin A supplementation, deworming is conducted twice each year in the Malezi Boracampaign and it is expected that caregivers could recall whether their child had received this ornot. Deworming coverage was, however, much lower than the coverage reported for vitamin Asupplementation.

Table 74 Deworming for children aged 24-59 months within past 6 months (n=447) - Ifo-2 camp, Dadaab(Sept 2012)

Dewormed % (95% CI)

301 / 44767.3%

(52.6 – 79.3)

Blanket Supplementary Feeding Programme (BSFP)Coverage of the blanket supplementary feeding program is low, which could indicate a problemwith collection and distribution of the product, and/or registration of the younger children if they


have been born since registrations closed in September 2011. Some respondents may havebeen confused as to which product the question was referring to as a sample of the CSB++ wasnot carried by the survey teams to show them.

Table 75 CSB++ Distribution (BSFP programme) for children aged 6-23 months - Ifo-2 camp, Dadaab(Sept 2012)


Currently receiving CSB++ 34 / 17719.2 %

(11.1 – 27.3)

The survey in Ifo-2 revealed much higher levels of diarrhoea in the past two weeks than the othercamps. This may have been a factor in the high levels of malnutrition. It may be related to thepoorer sanitation and hygiene situation in Ifo-2 (shown in results below).

Morbidity from diarrhoea and feeding during diarrhoea

Table 76 Prevalence of reported diarrhoea in the two weeks prior to the interview - Ifo-2 camp, Dadaab(Sept 2012)



(22.3 – 39.6)

Regarding the 195 children reported to have experienced diarrhoea in the past two weeks, themajority of these were fed less than normal during the episode of diarrhoea and a smallpercentage (see Table 77) were fed no food.

Table 77 Feeding during diarrhoea episodes - Ifo-2 camp, Dadaab (Sept 2012)

Feeding categoryN = 195

% (95% CI)

Less than normaln = 11860.5%

(43.9 – 77.1)

Same as normaln = 6432.8%

(18.2 – 47.5)

More than normaln = 73.6%

(0.6 – 6.5)

No foodn = 63.1%

(0.0 – 7.3)

CHILDREN 0-23 MONTHS - IFO-2 CAMP, DADAAB (Sept 2012)


Number/total %

Nationality

Somali 156 / 183 85.2%

Somali Bantu 27 / 183 14.8%

Others 0 / 183 0.0%

Arrival in camp

<3 months 0 / 183 0.0%

3-6 months 2 / 183 1.1%

6-9 months 1 / 183 0.5%


9-12 months 1 / 183 0.5%

Before September 2011 179 / 183 97.8%

Results of the IYCF questionnaire are summarised in the table below, which includes theresponses for four of the WHO core indicators and three optional indicators for IYCF, plus theprovision of other fluids to children, and also diarrhoea and feeding practices during diarrhoea ininfants.

Table 79 Prevalence of Infant and Young Child Feeding Practices indicators - Ifo-2 camp, Dadaab (Sept2012)

IndicatorAge range(months)

N/total Prevalence (%) 95% CI

Children ever breastfed 0-23 295 / 300 98.3% (96.7 – 100.0)

Early initiation of breastfeeding 0-23 201 / 300 68.1% (53.1 – 83.1)

Exclusive breastfeeding under 6 months 0-5 85 / 117 72.7% (62.2 – 83.1)

Continued breastfeeding at 1 year 12-15 40 / 51 78.4% (66.4 – 90.5)

Continued breastfeeding at 2 years 20-23 10 / 30 33.3% (15.1 – 51.6)

Introduction of solid, semi-solid or soft foods 6-8 17 / 34 50.0% (30.6 – 69.4)

Children bottle fed 0-23 10 / 300 3.3% (1.1 – 5.6)

Children given infant formula 0-23 3 / 299 1.0% (0.0 – 2.2)

Children given milk or milk alternative 0-12 33 / 179 18.4% (12.2 – 24.7)

Children given Tea/coffee 0-23 121 / 300 40.3% (33.0 – 47.7)

Children given water or sugar water 0-6 31 / 119 26.1% (16.0 – 36.1)

Reported prevalence of diarrhoea 0-23 50 / 300 16.7% (10.2 – 23.1)

Continued feeding during diarrhoea 0-23 17 / 50 34.0% (19.8 – 51.9)

As there are no previous results for Ifo-2 no comparison can be made for IYCF indicators. Whilstsome indicators are at desirable levels, others are concerning such as; only one third continuingbreastfeeding at 2 years and the prevalence of giving sugar/sugar water before 6 months andonly half reporting to have introduced solid/semi-solid/soft food between 6 – 8 months.

WOMEN 15-49 YEARS - IFO-2 CAMP, DADAAB (Sept 2012)



Somali 292 / 333 87.7%Somali Bantu 41 / 333 12.3%Others 0 / 333 0.0%

Arrival in camp<3 months 0 / 333 0.0%3-6 months 3 / 333 0.9%6-9 months 3 / 333 0.9%9-12 months 2 / 333 0.6%>12 months 325 / 333 97.6%

Physiological statusPregnant 70/333 21.0%Lactating (until 6 months post-natal only) 86 / 333 25.8%Neither lactating nor pregnant 177 / 333 53.2%Age of WomenMean Age 28.6 years

For Ifo-2, one in three women have anaemia with a haemoglobin level of <12.0 g/dL as shown inthe table below. Most of these cases are mild. However there are a number of moderate casesand only two were severely anaemic.


Table 81 Prevalence of anaemia and haemoglobin concentration in non-pregnant women of reproductiveage (15-49 years) - Ifo-2 camp, Dadaab (Sept 2012) (n = 261)

Anaemia – Non-pregnant womenof reproductive age 15-49 years

Number of casesPrevalence

(95% CI)

Total Anaemia (<12.0 g/dL)n=87

33.3%(25.4 – 41.3)

Mild Anaemia (11.0-11.9 g/dL)n=52

19.9%(14.8 – 25.0)

Moderate Anaemia (8.0-10.9 g/dL)n=33

12.6%(7.5 – 17.8)

Severe Anaemia (<8.0 g/dL)n=2

0.8%(0.0 – 1.8)

Mean Hb12.4 g/dL

(Range 7.3 - 16.2)

Slightly more than two thirds of women are enrolled in the ANC programme and all but one of thewomen could produce their card. Two women reported that they do not currently receive theiron-folic acid supplement, despite being enrolled in the programme.

ANC enrolment and iron-folic acid supplementation coverage

Table 82 ANC enrolment and iron-folic acid pills coverage among pregnant women (15-49 years) - Ifo-2camp, Dadaab (Sept 2012)


Currently enrolled in ANC programme with card53 / 72

73.6%(59.3 – 87.9)

Currently enrolled in ANC programme with card orrecall

54 / 7275.0%

(61.0 - 89.0)Currently receiving iron-folic acid pills

51 / 7270.8%

(56.7 – 84.9)

Less than half of the women having delivered a baby in the past six months had Vitamin Asupplementation recorded on their card, with the majority being able to recall receiving thesupplement after delivery.

Table 83 Post-natal vitamin A supplementation among women (15-49 years) - Ifo-2 camp, Dadaab (Sept2012)


Received vitamin A supplementation since deliverywith card

N = 34 / 8639.5%

(21.0 – 56.1)Received vitamin A supplementation since deliverywith card or recall

N = 73 / 8684.9%

(74.2 – 95.6)

HOUSEHOLD-LEVEL INDICATORS - WASH AND FOOD SECURITY -IFO-2 CAMP, DADAAB (SEPT 2012)

Table 84 indicates that the target sample size for household indicators was exceeded. Allhouseholds were considered whether or not they had eligible individuals for the individual-level


measurements.

Table 84 Target sample size and actual number captured for HH Questionnaire during the survey - Ifo-2camp, Dadaab (Sept 2012)

IndicatorTarget

sample sizeHouseholdinterviewed

during the study

% of the target

WASH / Food Security 360 374 104%

WATER, SANITATION AND HYGIENE – IFO-2 CAMP, DADAAB (SEPT 2012)

In Ifo-2, there were no new arrivals within the three months prior to the survey, and very few (n=7)had arrived within the past 12 months. There was therefore no need to have an additionalanalysis for new or recent arrivals.



<3 months 0 / 374 0.0%3-6 months 3 / 374 0.5%6-9 months 1 / 374 0.3%9-12 months 4 / 374 1.1%>12 months 367 / 374 98.1%

Most households reported not having enough containers to collect water, demonstrating asignificant and urgent need in Ifo-2. Less than 4% responded that they had enough containers.

Table 86 Ownership of adequate water containers - Ifo-2 camp, Dadaab (Sept 2012)


14 / 3743.7%

(0.5 – 7.0)

All households surveyed collect water from the public tap or standpipe in Ifo-2, as shown below.

Table 87 Proportion of HH using an improved drinking water source - Ifo-2 camp, Dadaab (Sept 2012)

Number / Total % (95%CI)

Source

Public Tap / Standpipe 374 / 374 100.0%

More than four out of every five households surveyed are satisfied with the water supply. For the16.2% that stated they were not satisfied, the reasons are outlined below - the majority statingthat the amount of water is not enough.

Table 88 Satisfaction with water supply - Ifo-2 camp, Dadaab (Sept 2012)

Number/total % (95% CI)Proportion of households that say they are satisfied withthe drinking water supply

317 / 37484.8%

(74.0 – 95.5)

Reasons for not being satisfied with water supply; N = 36 (amount is not enough) N = 5 (long queue) N = 1 (water point is far)

A high proportion of households received soap in the last two distribution cycles which is a goodresult. There remain about 10% of households not receiving soap, despite all of the householdsreporting to be registered.


Table 89 Soap distribution - Ifo-2 camp, Dadaab (Sept 2012)

Number/total % (95% CI)Proportion of households that received soap during the lasttwo distribution cycles or at reception

337 / 37490.1%

(85.2 – 95.0)

About half of surveyed households in Ifo-2 used a toilet that is not shared, however a significantnumber (n = 39) reported not using a toilet at all (i.e. using a plastic bag, the bush, field). Inaddition, about one third of household that have access to a toilet were sharing it between a totalof three or more households (see tables below).

Table 90 Safe Excreta disposal - Ifo-2 camp, Dadaab (Sept 2012)


Proportion of households using an improved excretadisposal facility (improved toilet facility, not shared)

192 / 37451.3%

(36.5 – 66.2)

Proportion of households using an improved excretadisposal facility (improved toilet facility, shared)

142 / 37438.0%

(23.0 – 51.9)

Proportion of households using an unimproved toilet1 / 374

0.3%(0.0 – 0.8)

Proportion of households using a plastic bag, the bush, orfield

39 / 37410.4%

(3.0 – 17.9)

FOOD SECURITY- IFO-2 CAMP, DADAAB (SEPT 2012)The majority of households in Ifo-2 had between three and seven persons. Of the 374 HHinterviewed, the smallest HH contained 1 person and the largest contained 11 people, theaverage household size being 6.1 people (refer table below).

Figure 22 Household size – Ifo-2 Camp, Dadaab (Sept 2012)


Number/total

Average HH size 6.1 persons

All households surveyed in Ifo-2 were registered and had a ration card. Most households report


that the food ration lasted less than the 15 day cycle.

Table 92 Ration card coverage and duration of general food ration - Ifo-2 camp, Dadaab (Sept 2012)


Proportion of households with a ration card 374 / 374100.0%

(100.0 – 100.0)Proportion of households reporting that the GFRlasted <15 days

349 / 37493.3%

(89.7 – 97.0)

Table 93 Duration of 15 days cycle that the General Food Ration lasted – Ifo-2 camp, Dadaab (2012)

Number days 95% CI

Average number of days GFR lasts 10.3 9.8 – 10.7

When asked why the general food ration did not last the entire cycle, the main reason given bythe responding households was that some food was sold or exchanged (n = 105) followed by theration not being big enough (n=184). Some reported scooping/other as the reason (n=33) or thatit was shared with kin (n=24), and only a few answered that it was shared with livestock (n=2) orbecause new arrivals had joined (n=1) (see Figure below).

Being the first of the surveys, the teams simply recorded the response that most householdsstated the food ration was not enough. When this was noticed, teams were instructed to probefurther to find out why the ration was not big enough or not lasting. That particular responsecould not be removed after the survey began, however this will be considered for the next surveyas it does not provide any useful information.

Figure 23 Main reason given by each household for why the general good ration did not last until the nextdistribution - Ifo-2 camp, Dadaab (Sept 2012)

As shown in Figure 24 below, the most important coping strategy that was reported to be used tofill the food gap was to borrow or receive credit from family, friends or neighbours. Only a smallpercentage were able to buy extra food and some reported eating less (both amount andfrequency).


Figure 24 Main coping strategies used to fill the food gap when general food ration runs out - Ifo-2 camp,Dadaab (Sept 2012)

Just under one third of households reported selling or exchanging food from the ration.

Table 94 Sell or exchange of food from the general ration - Ifo-2 camp, Dadaab (Sept 2012)

Number/total %

Proportion of households selling orexchanging food ration items

114 / 374 30.5%

As shown in Figure 25 below, when food from the general ration was sold or exchanged, themost common items reported to be bought amongst households in Ifo-2 were rice/pasta/potatoes(n=?) and milk (n=84).


Figure 25 Most common items bought when general ration is sold or exchanged - Ifo-2 camp, Dadaab(Sept 2012)




Has insecurity prevented anyone in your household from collecting the GFD in the last 2months?



RESULTS FROM KAMBIOOS CAMP, DADAAB (SEPT 2012)

INDIVIDUAL-LEVEL INDICATORS;CHILDREN 6-59 MONTHS,INFANTS AND YOUNG CHILDREN 0-23 MONTHS,WOMEN OF REPRODUCTIVE AGE 15-49 YEARS

HOUSEHOLD INDICATORS: WASH AND FOOD SECURITY MORTALITY

Table 95 provides the planned sample size and the actual units sampled during the survey foreach target population group. Thirty clusters were sampled for all indicators, therefore thenumber of required records per cluster varied according to the total target sample size required.

Table 95 Target sample size and actual number captured during the survey - Kambioos camp, Dadaab(Sept 2012)



during the survey

% of the target

Children 6-59 months 600 599 99.8%


Women 15-49 years 300 316 105%

CHILDREN 6-59 MONTHS-KAMBIOOS CAMP, DADAAB (SEPT 2012)

Whilst the majority of children 6-59 months in Kambioos are Somali, about 5% arrived from theLower Juba, Gedo and Lower Shabelle regions of Somalia in the past 12 months.

Table 96 Demographic information - Kambioos camp, Dadaab (Sept 2012)

Number/total %

Nationality

Somali 559 / 599 93.3%

Somali Bantu 40 / 599 6.7%

Others 0 / 599 0.0%

Arrival in camp

<3 months 1 / 599 0.2%

3-6 months 18 / 599 3.0%

6-9 months 4 / 599 0.7%

9-12 months 7 / 599 1.2%

>12 months 569 / 599 94.9%

Region of origin for children incamp for <12 months

Lower Juba 21 / 30 70.0%

Middle Juba - -

Gedo 3 / 30 10.0%

Bay - -

Bakool - -

Lower Shabelle 6 / 30 20.0%

Middle Shabelle - -

Hiraan - -


Mogadishu/Banadir - -

Other - -

Anthropometric results (based on WHO Growth Standards 2006)

The coverage of age documentation was very low with 28% of children having an exact birthdate. The age group 18 – 29 months was slightly over-represented and 30-41 months under-represented as compared to the other age groups. This is often the case in surveys where thereare limited proofs of age as caregivers tend to recall best the birth date of smaller children.

Table 97 Distribution of age and sex of sample - Kambioos camp, Dadaab (Sept 2012)

Boys Girls Total RatioAge (mo) no. % no. % no. % Boy:girl6-17 68 51.9 63 48.1 131 21.8 1.118-29 81 54.7 67 45.3 148 24.7 1.230-41 62 51.2 59 48.8 121 20.2 1.142-53 71 54.6 59 45.4 130 21.7 1.254-59 42 60.0 28 40.0 70 11.7 1.5Total 324 54.0 276 46.0 600 100.0 1.2

There were more boys than girls surveyed in Kambioos, as per the sex-ratio of 1.18, however thisfell within the acceptable range of 0.8 – 1.2.

According to weight-for-height indices, Kambioos had a 17.1% (95% CI 14.4-20.3) GAM and6.4% (95% CI 4.5-8.9) SAM, which constitute a ‘critical’ situation as the GAM prevalence sitsabove the nutrition emergency threshold of 15%. For GAM, MAM and SAM, boys appear to beaffected by malnutrition more than girls, as seen in Table 98 below.

Table 98 Prevalence of acute malnutrition based on weight-for-height z-scores (and/or oedema) and bysex - Kambioos camp, Dadaab (Sept 2012)

Alln = 594

Boysn = 322

Girlsn = 271


10217.2%

(14.4 – 20.3)

6119.0%

(15.9 – 22.5)

4115.0%

(10.8 – 20.5)Prevalence of moderate malnutrition(<-2 z-score and >=-3 z-score, no oedema)

6410.8%

(8.2 – 14.0)

4012.5%

(9.5 – 16.1)

248.8%

(5.5 – 13.7)

Prevalence of severe malnutrition(<-3 z-score and/or oedema)

386.4%

(4.6 – 8.9)

216.5%

(4.3 – 9.9)

176.2%

(3.4 – 11.0)The prevalence of oedema is 0.7 % (n=4)

As for Ifo-2, Kambioos is a new camp since the 2011 survey, therefore no trend or comparisoncan be made.

In both severe and moderate categories of malnutrition the age groups of 6 -17 months and 18-29 months have the highest prevalence. Children above 54 months also show significant rates ofmoderate wasting (see table below).


Table 99 Prevalence of acute malnutrition by age, based on weight-for-height z-scores and/or oedema -Kambioos camp, Dadaab (Sept 2012)


Moderatewasting

(>= -3 and <-2 z-score )


Oedema

Age(mo)

Totalno.

No. % No. % No. % No. %

6-17 130 19 14.6 18 13.8 93 71.5 0 0.018-29 146 8 5.5 17 11.6 120 82.2 1 0.730-41 120 1 0.8 8 6.7 110 91.7 1 0.842-53 128 4 3.1 12 9.4 110 85.9 2 1.654-59 70 2 2.9 9 12.9 59 84.3 0 0.0Total 594 34 5.7 64 10.8 492 82.8 4 0.7

Proportionally, infants 6-17 months show the highest prevalence of severe malnutrition by far andalso the highest rate of moderate wasting. The other age groups affected to a similar extent aseach other are 18-29 months and 54-59 months.

Figure 26 Trends in the prevalence of wasting by age in children 6-59 months - Kambioos camp, Dadaab(Sept 2012)

Table 100 below illustrates once more that children with nutritional oedema tend to have aweight-height z-score >-3. As with the other two camps, all cases of oedema in Kambioos areclassified as kwashiorkor as their weight is increased by a significant accumulation of fluid.

Table 100 Distribution of severe acute malnutrition and oedema based on weight-for-height z-scores -Kambioos camp, Dadaab (Sept 2012)

<-3 z-score >=-3 z-score

Oedema presentMarasmic kwashiorkor

N = 0Kwashiorkor

N = 4

Oedema absentMarasmic


N = 558


Figure 27 Distribution of weight-for-height z-scores (based on WHO Growth Standards; the referencepopulation is shown in green) of survey population compared to reference population - Kambioos camp,Dadaab (Sept 2012)

Table 101 Prevalence of stunting based on height-for-age z-scores and by sex - Kambioos camp, Dadaab(Sept 2012)

Alln = 569

Boysn = 305

Girlsn = 264


n = 16128.3%

(23.1 – 34.3)

n = 9430.8%

(25.4 – 37.4)

n = 6725.4%

(18.4 – 33.9)Prevalence of moderatestunting(<-2 z-score and >=-3 z-score)

n= 10818.5%

(14.7 – 23.0)

n = 6421.0%

(16.6 – 26.7)

n = 4115.5%


n = 569.8%

(7.4 – 13.1)

n = 309.8%

(7.2 – 13.3)

n = 269.8%

(6.2 – 15.2)

Children in the age groups 6-17 months, 18-29 month and 30-41 months are the most affected bystunting in Kambioos suggesting that the malnutrition is setting in very early on for these children.Some of the older children under 5 years may have also experienced malnutrition prior to arrivingin Dadaab as seen by the 24.6% of 54 – 59 months and 26.3% of 42-53 months children beingstunted. This can also be seen in Figure 28 below.


Table 102 Prevalence of stunting by age based on height-for-age z-scores - Kambioos camp, Dadaab(Sept 2012)


Moderatestunting

(>= -3 and <-2 z-score )


Age(mo)

Totalno.

No. % No. % No. %

6-17 122 15 12.3 21 17.2 86 70.518-29 137 19 13.9 23 16.8 95 69.330-41 115 13 11.3 20 17.4 82 71.342-53 126 3 2.4 30 23.8 93 73.854-59 69 6 8.7 11 15.9 52 75.4Total 569 56 9.8 105 18.5 408 71.7

Figure 28 Prevalence of stunting (including severity) by age in children 6-59 months - Kambioos camp,Dadaab (Sept 2012)

The prevalence of underweight, indicated by the weight-for-age z scores of surveyed children, isalso high in Kambioos suggesting it is a ‘serious’ public health concern. Total and also moderateunderweight is seen to be slightly higher in boys than in girls.

Table 103 Prevalence of underweight based on weight-for-age z-scores by sex - Kambioos camp, Dadaab(Sept 2012)

Alln = 585

Boysn = 317

Girlsn = 268


n = 16828.7%

(25.1 – 32.7)

n = 9630.3%

(25.5 – 35.6)

n = 7226.9%


n = 11719.7%

(16.7 – 23.7)

n = 6520.5%

(16.2 – 25.6)

n = 5219.4%

(15.4 – 24.2)

Prevalence of severeunderweight (<-3 z-score)

n = 518.7%

(6.9 – 11.0)

n = 319.8%

(7.2 – 13.2)

n = 207.5%

(4.8 – 11.5)


The statistical measures of each nutritional index for the surveyed children in Kambioos areshown below. The four z-scores unavailable represent four cases of oedema. The design affectfor height-for-age suggests the children in Kambioos are more heterogeneous regarding height.All three mean z-scores are <0 (i.e. negative) confirming the concerning malnutrition situation inKambioos.

Table 104 Mean z-scores, Design Effects and excluded subjects - Kambioos camp, Dadaab (Sept 2012)

IndicatorN Mean z-scores

± SDDesign Effect(z-score < -2)



Weight-for-Height 590 -0.88±1.23 1.00 4 6

Weight-for-Age 585 -1.41±1.12 1.00 4 11

Height-for-Age 569 -1.43±1.15 2.16 0 31

The current screening tool in the camps is MUAC measurement and it is a good indicator of riskof mortality in children under 5. Table 105 below, shows little correlation between MUAC resultsand GAM and SAM based on weight-for-height.

Table 105 Prevalence of malnutrition based on MUAC (N=599) - Kambioos camp, Dadaab (Sept 2012)



Prevalence of MUAC < 12.5 cm and/or oedeman=569.3 %

(7.2 - 12.1)

Prevalence of MUAC < 12.5 cm and >= 11.5 cm, nooedema

n=396.5 %

(4.7 - 8.9)

Prevalence MUAC < 11.5 cm and/or oedeman=172.8 %

(1.6 - 4.8)

The caseloads for the selective feeding programmes were estimated to aid in future programmeplanning. The total population estimate for Kambioos used during the survey was 14,205 (basedon UNHCR ProGres data). The total population of the surveyed households and the proportionthat were under 5 years of age was calculated from the household listing forms (and householdquestionnaires). It was found that approximately 30.7% of the surveyed population in Kambiooswas under-5 years, which was equivalent to 4,360 infants and children in the whole of Kambioos.It was assumed that 10% of under-fives were 0-5 months, so it could be estimated that 3,924children were 6-59 months. This figure was then multiplied by the estimated proportion of childreneligible to be enrolled in either TFP or TSFP for Kambioos to give the estimated caseload.

Table 106 Estimated number of malnourished children aged 6-59 months eligible to be enrolled in aselective feeding programme at the time of the survey (based on all admission criteria) - Kambioos camp,Dadaab (Sept 2012)



Eligible for Therapeutic FeedingProgramme**

7.2%(5.1 – 9.2)

283

Eligible for TargetedSupplementary FeedingProgramme**

12.7%(9.5 – 15.8)

498



Anaemia results

Half of the children surveyed in Kambioos have anaemia (Hb < 11.0g/dL) indicating that theprevalence of anaemia in Kambioos is high according to WHO classifications (<40%). See Table107 below for the prevalence of anaemia by severity.

Table 107 Prevalence of anaemia and haemoglobin concentration in children 6-59 months of age -Kambioos camp, Dadaab (Sept 2012) (n = 599)

Anaemia – Children 6-59 monthsNumber of cases

Prevalence(95% CI)


(45.3 – 56.2)


(25.4 – 33.4)


(17.0 – 25.0)


(0.0 – 0.8)

Mean Hb10.8 g/dL

(Range 6.0 - 16.7)

Table 108 illustrates that also in Kambioos, the younger children aged 6-23 months have thehighest prevalence of anaemia. Also, the two cases of severe anaemia were in these youngerage groups. The level of moderate anaemia in infants was more than double that of children 36-59 months, as seen below.

Table 108 Prevalence of anaemia by age - Kambioos camp, Dadaab (Sept 2012)

SevereAnaemia

(<7.0 g/dL)

ModerateAnaemia

(7.0-9.9 g/dL)

Mild Anaemia(Hb 10.0-10.9

g/dL)

Total Anaemia(Hb<11g.0

g/dL)

Normal(Hb≥11.0 g/dL)

Age(mo)

Totalno.

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

No. %(95% CI)

6-23 206 10.5%(0.0 –1.5)

6531.6%(23.8 –39.3)

7134.5%(27.4 –

1.5)137

66.5%(58.3 –74.8)

6933.5%(25.2 –41.7)

24-35 126 10.8%(0.0 –2.4)

3023.8%(17.1 –30.5)

3628.6%(21.7 –35.4)

6753.2%(43.5 –62.8)

5946.8%(37.2 –56.5)

36-59 267 0 0.0% 3111.6%(7.9 –15.4)

6925.8%(20.4 –31.3)

10037.5%(29.7 –45.3)

16762.5%(54.8 –70.3)

Total 304 20.3%(0.0 –0.8)

12621.0%(17.0 –25.0)

17629.4%(25.4 –33.4)

30450.8%(45.3 –56.2)

29549.2%(43.8 –54.7)

Programme coverage


Selective feeding programmesCoverage rates in Kambioos of both the TFP and targeted SFP are very low as seen by Table109 below, with reference to the target coverage of >90%.

Table 109 Acute malnutrition treatment programme coverage based on all admission criteria (weight-for-height, MUAC, oedema) – Kambioos camp, Dadaab (Sept 2012)


Proportion of children aged 6-59 months with Severe AcuteMalnutrition currently enrolled in Therapeutic Feeding Programme*

7 / 4316.3%

(5.6 – 38.7)

Proportion of children aged 6-59 months with Moderate AcuteMalnutrition currently enrolled in Supplementary FeedingProgramme*

12 / 7615.8%

(9.4 – 25.3)

*WHZ flags excluded

Similar to the other two surveys in Dadaab there are many more (almost double) children eligiblefor therapeutic nutrition programmes when using weight-for-height, oedema and MUAC than ifusing MUAC only, as seen by comparing the table below with the table above.

Table 110 Acute malnutrition treatment programme coverage based on MUAC and oedema only -Kambioos camp, Dadaab (Sept 2012)


Proportion of children aged 6-59 months with Severe AcuteMalnutrition currently enrolled in Therapeutic Feeding Programme

6 / 1735.3%

(10.3 – 70.2)

Proportion of children aged 6-59 months with Moderate AcuteMalnutrition currently enrolled in Supplementary FeedingProgramme

13 / 3933.3%

(20.5 – 49.2)

The coverage when using MUAC alone is also low, considering the coverage should be >90%.This means many children are not being screened and referred into programmes when needed.

Blanket Supplementary Feeding Programme (BSFP)Coverage of the blanket supplementary feeding program is low, which may indicate a problemwith collection and distribution of the product, and/or registration of the younger children if theyhave been born since registrations closed in October 2011. The latter theory, however, does notaccount for the 90.7% of children that reported not receiving the supplementary food, CSB++.Some respondents may have been confused as to which product the question was referring towithout a sample to show them.

Table 111 CSB++ Distribution (BSFP programme) for children aged 6-23 months- Kambioos camp,Dadaab (Sept 2012)


Currently receiving CSB++ 19 / 2049.3%

(2.9 – 15.7)


Measles vaccination coverageFollowing the outbreak of measles in the first half of 2012 in Dadaab, it is important to know themeasles vaccination coverage, as there had been no mass measles vaccination for Kambioos asit is a new camp since the last mass measles vaccination campaign early in 2011. It is thereforeexpected that the vaccination coverage may be lower in Kambioos, as seen by the proportionhaving cards to confirm measles vaccination. There was a significant difference between thosecaregivers recalling the vaccination of their child compared to the proportion having cards, which


could mean either the use of EPI cards is not adequate in Kambioos or the respondent wasconfused about which vaccination the question referred to.

Table 112 Measles vaccination coverage for children aged 9-59 months (n=584) – Kambioos camp,Dadaab (Sept 2012)



n=6110.4%

(3.4 – 17.4)

n=56496.6%

(93.9 – 99.2)

PENTA vaccination coveragePENTA vaccination coverage was measured in light of a potential outbreak of pertussis(whooping cough), and is a routine vaccination for children under 5 years.

Table 113 PENTA vaccination coverage for children aged 6-59 months (n=599) - Kambioos camp, Dadaab(Sept 2012)

PENTA 1 (only)n = 12

PENTA 2n = 97

PENTA 3n = 313


confirmation)

2.0%(0.1 – 3.9)

16.2%(9.0 – 23.4)

52.3%(39.9 – 64.6)

The remaining 29.5% of children 6 – 59 months (n = 177) had not received any PENTA doses.

Vitamin A supplementation was a focus of the Malezi Bora campaign in May 2012 and it istherefore expected that even if not recorded on the child’s card, that the caregiver could recallwhether the child received it or not. The coverage in Kambioos for Vitamin A supplementation bycard or recall was high.

Vitamin A supplementation coverage

Table 114 Vitamin A supplementation for children aged 6-59 months within past 6 months (n=599) –Kambioos camp, Dadaab (Sept 2012)


n= 35

Vitamin A capsule(with card or confirmation from mother)

n= 5695.8%

(2.9 – 8.7)94.8%

(90.9 – 98.8)

Deworming coverageDeworming of children aged 24 – 59 months was measured by recall only as it is not routinelyrecorded on the cards. As with Vitamin A supplementation, deworming is conducted twice eachyear in the Malezi Bora campaign, and it was expected that caregivers could recall whether theirchild had received this or not. Deworming coverage is, however, lower than the reported vitaminA supplementation coverage.

Table 115 Deworming for children aged 24-59 months within past 6 months (n=599) – Kambioos camp,Dadaab (Sept 2012)

Dewormed %

502 / 59983.8%

(77.8 – 89.8)

Morbidity from diarrhoea and feeding during diarrhoeaThe survey in Kambioos revealed relatively high levels of diarrhoea in the past two weeks in


children 6-59 months. This may be a contributing factor in the higher levels of malnutrition andmay also be related to the poorer sanitation and hygiene situation in Kambioos (seen by resultsfurther below).

Table 116 Prevalence of reported diarrhoea in the two weeks prior to the interview - Kambioos camp,Dadaab (Sept 2012)



(7.8 – 17.3)

Of those children reportedly having diarrhoea in the past two weeks, more than three quarterswere fed less than normal, compromising their nutritional status, and less than 15% were fed thesame as normal. The current recommendations are to continue feeding normally during episodesof diarrhoea.

Table 117 Feeding during diarrhoea episodes - Kambioos camp, Dadaab (Sept 2012)

Feeding practices n = 75% (95% CI)

Less than normaln = 6485.3%

(66.4 – 100.0)

Same as normaln = 1114.7%

(0.0 – 33.6)More than normal n = 0No food n = 0

CHILDREN 0-23 MONTHS - KAMBIOOS CAMP, DADAAB (Sept 2012)

There were very few children 0-23 months arriving in the camp since the last survey (only 3.7%).The remaining 313 infants were either born in Kambioos of arrived prior to October 2011.




Date of arrival in camp<3 months 0 / 325 0.0%3-6 months 8 / 325 2.5%6-9 months 2 / 325 0.6%9-12 months 2 / 325 0.6%Before October 2011 313 / 325 96.3%

The IYCF questionnaire results are given in the table below, which includes the responses forfour of the WHO core Indicators and three optional indicators for IYCF, plus the provision of otherfluids to children, and also diarrhoea and feeding practices during diarrhoea in infants.


Table 119 Prevalence of Infant and Young Child Feeding Practices indicators - Kambioos camp, Dadaab(Sept 2012)

Indicator Age range Number/total Prevalence (%) 95% CI

Children ever breastfed 0-23 months 315 / 324 97.2% (95.0 – 99.5)

Early initiation of breastfeeding 0-23 months 275 / 314 87.6% (78.6 – 96.6)

Exclusive breastfeeding under 6 months 0-5 months 101 / 120 84.3% (77.1 – 91.3)

Continued breastfeeding at 1 year 12-15 months 28 / 49 57.1% (40.2 – 74.0)

Continued breastfeeding at 2 years 20-23 months 18 / 55 32.7% (18.2 – 47.2)

Introduction of solid, semi-solid or soft foods 6-8 months 3 / 15 20.0% (0.0 – 46.1)

Children bottle fed 0-23 months 14 / 314 4.3% (1.7 – 6.9)

Children given infant formula 0-23 months 20 / 323 6.2% (1.0 – 11.4)

Children given milk or milk alternative 0-12 months 24 / 173 13.9% (7.9 – 19.9)

Children given Tea/coffee 0-23 months 104 / 324 32.1% (21.7 – 42.5)

Children given water or sugar water 0-5 months 2 / 120 1.7% (0.0 – 4.0)

Reported prevalence of diarrhoea 0-23 months 35 / 324 10.8% (5.7 – 15.9)

Continued feeding during diarrhoea 0-23 months 0 / 35 0.0% -

No comparison can be made for these IYCF indicators as it is the first survey in Kambioos since ithas been occupied by relocated refugees. Whilst some indicators are at desirable levels, othersare very concerning such as; less than one third continuing breastfeeding at 2 years, 6.2% (95%CI 1.0-11.4) giving infant formula and only 20% (95% CI 0-46.1) having introduced solid/semi-solid/soft food between 6 – 8 months. Also the percentage of infants given tea/coffee is ofconcern.

WOMEN 15-49 YEARS - KAMBIOOS CAMP, DADAAB (Sept 2012)




Arrival in camp<3 months 2 / 316 0.6%3-6 months 7 / 316 2.2%6-9 months 2 / 316 0.6%9-12 months 3 / 316 0.9%>12 months 302 / 316 95.6%

Physiological status

Pregnant 58 / 316 18.4%Lactating (until 6 months post-natalonly)

68 / 31621.5%

Neither lactating nor pregnant 190 / 316 60.1%Age of Women

Mean Age 29.2

Almost one third of non-pregnant women 15-49 years are anaemic (Hb <12.0g/dL) and more thanhalf of the women in this group are moderately anaemic.


Table 121 Prevalence of anaemia and haemoglobin concentration in non-pregnant women of reproductiveage (15-49 years) - Kambioos camp, Dadaab (Sept 2012) (n = 256)

Anaemia categoriesNumber of cases

Prevalence(95% CI)

Total Anaemia (<12.0 g/dL)n = 8232.0%

(23.7 – 40.3)

Mild Anaemia (11.0-11.9 g/dL)n = 3212.5%

(8.5 – 16.5)


(11.4 – 26.8)


(0.0 – 1.2)

Mean Hb12.3 g/dL

(Range 7.7 – 15.2)

ANC enrolment and iron-folic acid supplementation coverageTable 122 indicates that coverage of ANC programme in Kambioos is good with almost all of the pregnantwomen enrolled and confirmed with their card. However there were six women who are enrolled andstating that they are not currently receiving iron-folic acid pills.

Table 122 ANC enrolment and iron-folic acid pills coverage among pregnant women (15-49 years) -Kambioos camp, Dadaab (Sept 2012)


Currently enrolled in ANC programme with card 56 / 5896.6%

(91.3 – 100.0)Currently enrolled in ANC programme with card orrecall

56 / 5896.6%

(91.3 – 100.0)

Currently receiving iron-folic acid pills 50 / 5886.2%

(72.4 – 100.0)

Table 123 Post-natal vitamin A supplementation among women (15-49 years) - Kambioos camp, Dadaab(Sept 2012)

Number/total % (95% CI)Received vitamin A supplementation since delivery withcard

33 / 6848.5%

(30.8 – 66.2)Received vitamin A supplementation since delivery withcard or recall

64 / 6894.1%

(88.3 – 99.9)

HOUSEHOLD-LEVEL INDICATORS - WASH AND FOOD SECURITY-KAMBIOOS CAMP, DADAAB (SEPT 2012)

Table 124 shows the different indicators and the total number of households who were sampledfor each household-level indicator. All households were considered whether or not they hadeligible individuals for the individual-level measurements.


Table 124 Target sample size and actual number captured for HH Questionnaire during the survey -Kambioos camp, Dadaab (Sept 2012)

Indicator Targetsample size

Householdinterviewed during

the study

% of the target

WASH / Food Security 360 447 124%

WATER, SANITATION AND HYGIENE - KAMBIOOS CAMP, DADAAB (SEPT 2012)

In Kambioos, three households arrived within the last 3 months, and 17 in total had arrived withinthe 11 months prior to September 2012. There was therefore no need to carry out an additionalanalysis for new or recent arrivals.



<3 months 3 / 447 0.7%3-6 months 10 / 447 2.2%6-9 months 1 / 447 0.2%9-11 months 4 / 447 0.9%

>11 months 429 / 447 96.0%

Table 126 indicates that less than one quarter of households surveyed have enough containersto collect sufficient water. This highlights an important need as water and sanitation are closelylinked to health and malnutrition.

Table 126 Ownership of adequate water containers - Kambioos camp, Dadaab (Sept 2012)


99 / 44022.5%

(13.3 – 31.7)

Most households in Kambioos collect water from a public tap or standpipe, with a smallpercentage receiving water from a UNHCR tanker. Six households that were not registered werenot asked this question.

Table 127 Main source of drinking water for HH - Kambioos camp, Dadaab (Sept 2012)

Source Number / Total % (95%CI)

Public Tap / Standpipe 427 / 44196.8%

(90.3 – 100.0)

UNHCR Tanker 14 / 4413.2%

(0.0 – 9.7)

Despite many households not having enough water containers, almost all households surveyedreported being happy with the water supply. The five households that stated they were not happycited the reasons given below in Table 128.

Table 128 Satisfaction with water supply - Kambioos camp, Dadaab (Sept 2012)

Number/total % (95% CI)Proportion of households that say they are satisfied withthe drinking water supply

436 / 44198.9%

(97.0 – 100.0)

Reasons for not being satisfied with water supply N= 3 (amount not enough) N= 1 (long queue) N= 1 (water point is far)

Coverage of soap distribution was excellent with only 5 households not receiving soap in the last


2 distribution cycles (1.2%).

Table 129 Soap distribution - Kambioos camp, Dadaab (Sept 2012)

Number/total % (95% CI)Proportion of households that received soap during thelast two distribution cycles or at reception

429 / 43498.8%

(97.6 – 100.0)

Table 130 indicates the types of toilets used by the households in Kambioos camp. Fifteenhouseholds (3.4%) do not use a toilet (i.e. they use a plastic bag, the bush, or field).

Table 130 Safe Excreta disposal - Kambioos camp, Dadaab (Sept 2012)

Excreta disposal methods Number/total % (95% CI)

Proportion of households using an improved excretadisposal facility

18 / 4414.1%

(1.7 – 6.4%)Proportion of households using a shared family toilet

121 / 44127.4%

(18.5 – 36.4)Proportion of households using a communal toilet

286 / 44164.9%

(54.3 – 75.4)Proportion of households using an unimproved toilet

16 / 4413.6%

(0.1 – 7.1)

FOOD SECURITY - KAMBIOOS CAMP, DADAAB (SEPT 2012)

The majority of households in Kambioos had between four and nine persons. Of 447 HHinterviewed, the smallest HH contained 1 person and the largest, 14 people and the averagehousehold size was 6.5 people (refer to the table below).

Figure 29 Household size – Kambioos Camp, Dadaab (Sept 2012)


Average HH size 6.5 persons

A total of eight households (of 447) were unregistered and did not have a ration card. Themajority of those registered reported that the food ration lasted less than 15 days, as shown inthe table below. The denominator for these two estimates is different because on two of thesurvey days, one particular team included the twelve households for the HH questionnaire but didnot complete the HH questionnaire for the additional three households required for the mortality


questionnaire (15 in per cluster) for Kambioos. Therefore six household who were registered didnot have the HH questionnaire administered to them.

Table 132 Ration card coverage and duration of general food ration - Kambioos camp, Dadaab (Sept2012)


Proportion of households with a ration card 439 / 44798.2%

(94.6 – 100.0)Proportion of surveyed HH who had one or moremembers that were not registered on the ration card

79 / 439 18.0%

Proportion of households reporting that the GFRlasted <15 days

414 / 43395.6%

(92.8 – 98.4)

For those reporting that the food ration lasted less than the 15 days of the cycle, the averageduration is shown in the table below.

Table 133 Duration that GFR lasts – Kambioos camp, Dadaab (Sept 2012)

Number days 95% CI

Average number of days GFR lasts 9.7 (9.1 – 10.3)

When asked why the general food ration did not last the entire cycle, the main reason given bythe 414 responding households was that some food was sold or exchanged (n=319) followed bythe ration not being big enough (n=35). Some reported ‘scooping/other’ as the reason (n=38) orthat it was shared with kin (n=12), and only a few answered that it was shared with livestock(n=3) or because new arrivals had joined (n=7).

Figure 30 Main reason given by each household for why general good ration did not last 15 days -Kambioos camp, Dadaab (Sept 2012)

As shown in Figure 31 below, the most important coping strategy that was reported to be used tofill the food gap was to borrow or receive credit from family, friends or neighbours. Although inKambioos there were more households reportedly reducing their food intake to cope (i.e. byreducing portion size or meal frequency per day) which is a concern particularly for youngchildren.


Figure 31 Coping strategies used to fill the food gap when general food ration runs out - Kambioos camp,Dadaab (Sept 2012)

Table 134 Selling or exchange of food from the general ration - Kambioos camp, Dadaab (Sept 2012)

Number/total %

Proportion of households selling or exchangingfood ration items

319 / 43977.1%

(69.3 – 84.8)

As shown in Figure 32 below, when food from the general ration was sold or exchanged, themost common items bought were sugar (n=301) and milk (n=303) with meat and vegetables alsoquite commonly replacing the ration.


Figure 32 Most common items bought when general ration is sold or exchanged - Kambioos camp,Dadaab (Sept 2012)




Has insecurity prevented anyone in your household from collecting the GFD in the last 2months?

2 / 440 households responded ‘yes’ (0.5%) - one HH did not respond.

MORTALITY- KAMBIOOS CAMP, DADAAB (SEPT 2012)

Retrospective mortality data was collected over the past three months. The exact recall periodwas 98 days as the local event used was World Refugee Day (June 20th 2012) which is markedby UNHCR in all camps and considered to be memorable to the refugee population.Demographic data was also derived from the mortality data as presented below.

Table 135 Demographic and retrospective mortality - Kambioos, Dadaab (Sept 2012)

Demographic dataNumber of HH surveyed 450Average HH size 6.5% U5 30.7%

Retrospective mortalityNumber of current HH residents 2912.5Total number U5 893Number of people who joined HH / camp 20Total number U5 who joined HH / camp 5Number of people who left HH / camp 42Total number U5 who left HH / camp 10Number of births during recall 86Number of deaths during recall 6


Total number U5 deaths during recall 5Crude Death Rate(total deaths/10,000 people / day)

0.21(0.10 - 0.45)

U5 Death Rate(deaths in children under five/10,000children under five / day)**

0.56(0.24 - 1.31)

**One household had a death recorded with no gender or age documented. It was known by the name thathe was male and it was assumed for analysis that he was less than 5 years old.


LIMITATIONS

This survey in 2012 is the first time for Dadaab that the annual nutrition survey was remotelysupervised due to the issue of insecurity. Contextual changes and a number of serioussecurity incidents throughout 2012 led to higher security risk and limited movement around thecamps. For Kenyan and expat staff, a police escort was required at the time of the survey. Itwas decided that the survey consultants should not be exposed to such high risk and theywere therefore based at the UNHCR Dadaab SO (formerly Dadaab Main Office).

Time constraints – due to administrative / contractual delays the 2012 survey was delayed andundertaken in late September and early October. Despite this delay, there was also pressureto complete the survey as quickly as possible so that results could be available for theupcoming UNHCR Joint Assessment Mission (JAM) in late October. This put the survey on atight schedule with little room for movement when extra time may have been useful (forexample – additional training on anthropometric techniques following the standardisation testfor some teams in each camp could have further minimised error and improved quality of thedata collected.

Difficulties in consistent and timely communication with some stakeholders left some decisionsdelayed or requiring amendment which led to inefficiencies. Some partners were much morededicated and it was also noticed that those staying within the compound or nearby were ableto meet more regularly with the survey co-ordination team for discussions, to receive supportand for other trouble-shooting throughout data collection.

Despite the promise of support and commitment to the survey, this was unreliable andinconsistent during the actual survey. The full involvement of all agencies was paramount toensure adequate supervision in the field during data collection, however this was not providedconsistently by all. Even though they were invited and requested, some meetings during thedata collection were not attended and communication was lacking.

Problems in leadership by the Nutrition Co-ordinators of some IPs was observed and this ledto a shift in power with the data collection teams, which were already recruited prior to surveyplanning. Those who had difficulty in leading and motivating their teams had poorer quality ofdata. It was noted that varying levels of commitment and support for the survey coming frommanagement within IPs and lack of survey experience of some nutrition co-ordinators meantthe importance of the survey and the commitment required was underestimated.

Data collection started as early in the day as possible, however due to movement restrictionsteams could not start data collection each day until later than planned. This meant teamswere spending longer in the blocks during the hotter part of the day causing discomfort. Thismay have impacted on data collection in some surveys. In addition, then length of the surveyeach day and for six consecutive days in such heat is very demanding and would have led tofatigue, also possibly affecting the results. However, the physical demands were lower duringthe 2012 survey than in previous surveys.

Whilst intensive training was given to supervisors, varying levels of experience and interestmeant that not all would have been capable to pick up technical errors and provide detailedand tailored guidance to their teams to the same extent as if the survey management teamcould have been present.

There was one survey manager to manage all the aspects of the survey in five camps.Despite the plan and best efforts to recruit an assistant survey manager this was not done byUCL within the available time and experience demonstrated that the management team wasinsufficient to cope with all aspects of the survey within the compressed time-frame.


Undertaking five surveys is a considerable task and with the added component of utilisingsmartphones for data collection, there were simply not enough personnel to manage theprocess. Higher levels of external inputs along with greater commitment from the IPs will berequired in future surveys to ensure success.

DISCUSSION

The 12 months leading up to the survey saw many changes to the Dadaab context including apoor security environment, withdrawal of many international and technical staff, and a likelyimpact on service delivery. Perhaps the most noteworthy change since the previous survey is thattwo extra camps are now in operation, which increased the number of surveys conducted in 2012from three to five. In contrast to 2011, the lead technical advisors for the survey were also notable to directly supervise field work in the camps due to insecurity. As previously stated, onlythree surveys are reported here. UNHCR took the decision not to release the results fromDagahaley and Ifo camp surveys due to concerns about data quality. This does, however, meanthat estimates for malnutrition prevalence and programme performance indicators are notcurrently available for these camps. There is an urgent need to conduct new surveys in these 2camps to enable this data to be obtained.

Another important limitation with the surveys reported here is that in Hagadera the ‘outskirt areas’were not included. Outskirt areas are areas of informal settlement on the edges of the formalcamp blocks. They developed in all 3 of the pre-existing camps and expanded rapidly during theemergency influx of refugees during 2011. While it was possible to map and survey the outskirtsareas in Dagahaley during the 2011 survey, this was impossible during 2012 in any of the campsdue to insecurity. The decision of the GOK to stop registration of refugees for periods during 2012also meant that there was greater uncertainty regarding the actual population size within thecamps. It is therefore very likely that the nutritional status reported here for Hagadera camp isbetter than would have been found if the sampling frame for the survey had included the whole ofthe main camp and outskirts combined.

Nutritional status of young children and mortalityResults from these three surveys indicates that the nutritional status of young children in Dadaabremains far from ideal, despite the improvement in malnutrition levels since the previous surveywhich was conducted at the height of the influx in 2011.

Levels of GAM dropped from 17.2% (13.2 – 22.1) to 10.3% (8.0 – 13.0) (p<0.05) in Hagadera,which is the only camp with a 2011 survey to make the comparison with. It also denotes that thelevel of malnutrition has shifted from ‘critical’ back to ‘serious’. On-going efforts are required tosustain and continue the improvements in GAM and SAM in Hagadera.

Being the first survey for both Ifo-2 and Kambioos, it provides an assessment to facilitate futureprogram planning and a benchmark for future surveys, but no trends are available. GAM in Ifo-2was 15.0% (12.3 – 18.0) whilst the survey in Kambioos revealed the highest of the three campswith a GAM of 17.1% (14.4 – 20.1). Both of these camps are classified as having a ‘critical’nutrition situation according to WHO thresholds.

Three oedema cases were identified in Hagadera (0.5%), 5 were detected in Ifo-2 (0.8%) and inKambioos 4 cases were found (0.7%). The finding of these cases in the population suggests thatthe screening and outreach components of nutrition programmes are not effectively identifyingand referring these cases, and/or that caregivers are not equipped to notice the oedema andchildren are becoming more malnourished before help is sought.

The mortality questionnaire was only administered in Kambioos. This camp was selected as itwas considered to have the most fragile population, since it is the most recent camp to bepopulated and have services introduced. Some services still remain to be set-up in Kambioos;


there is no hospital and food distributions occur in neighbouring Hagadera. It was thereforeconsidered likely that the other camps would have a lower mortality rate than Kambioos. Boththe crude mortality and the under-five mortality rates fell below the emergency thresholds; CDR0.21 deaths/10,000/day (0.10 – 0.45) and U5DR 0.56 deaths/10,000/day (0,24 – 1.31). Theselevels are comparable to those in Hagadera camp during the 2011 survey.

It is difficult to compare this rate to the mortality recorded in the HIS as the HIS mortality rate hasbeen erratic since the beginning of 2012 and problems with mortality surveillance were notedduring a CDC field investigation during 2011. According to the HIS, mortality seemed to bestabilising mid-year, however, the average U5DR across July – September (i.e. the same recallperiod) was 0.29/10,000/day a mortality rate which is an underestimate in comparison to thissurvey. Moreover, it is thought that the accuracy of the survey results may have been affectedand that mortality may be slightly higher than this if some deaths went unreported, despite effortsto dissociate the survey from official UNHCR registrations and distributions.

The prevalence of stunting from these surveys ranged from 25.7% (20.4 – 31.8) to 41.7% (37.3 –46.3) which are higher than in 2011 (range was 20.7% to 27.7%) and can be defined as a ‘poor’situation in Hagadera and Kambioos and ‘critical’ in Ifo-2 according to the WHO classifications.Results for Kambioos should be interpreted with caution as age documentation was low at 28%,however Ifo-2 and Hagadera had good coverage of age documentation. Ifo-2 had a very highrate of severe stunting in particular, 18.9% (15.3 – 23.2) indicating that the population of youngchildren in Ifo-2 are more vulnerable as this suggests they have been experiencing malnutritionover a longer period of time (i.e. chronic malnutrition) - possibly due to poor child feeding andcare practices and poor health seeking behaviour. In all three camps, the age group 18-29months experienced the highest stunting rates, followed by 6-17 months and 30-41 months aboutthe same level, which follows a similar pattern to previous years.

Prevalence of diarrhoea in the two weeks leading up to the survey ranged from 0.8% (0.1 – 1.5)in Hagadera to 31.0% (22.3 – 39.6) in Ifo-2, which is extremely high. Kambioos reported 12.7%.As diarrhoea is closely linked to nutritional status, the high prevalence of diarrhoea in Ifo-2 maysuggest that the malnutrition status could have declined further after the survey. In all threesurveys, feeding practices during diarrhoea were found to be very poor and worse than theprevious survey; between 60 – 85% of children were fed less food than usual when experiencingdiarrhoea. This lack of appropriate care further compounds the children’s risk of becomingmalnourished and/or failing to recover well from pre-existing malnutrition.

Poor sanitation, poor hygiene and poor water quality are contributing factors to the spread ofdiarrhoea, all of which are problems identified in areas of Kambioos and Ifo-2 camps (discussedlater in this section).

In general, it can be said that despite efforts to maintain nutrition programmes and other servicesin the Dadaab camps, reasons for continued high levels of malnutrition include:

- Previous or on-going exposure to malnutrition for the under 5 population leaving themwith an on-going risk of relapse. Many of the households in Ifo-2 and Kambioos wererelocated from other camps where they had been hosted by established refugeehouseholds and sharing their resources. In addition, the health and nutrition servicesduring the time of influx were overwhelmed and struggling to cope with the increasedneed during 2011. In addition poor health seeking behaviours and lack of knowledgehave been cited as reasons why the households in Kambioos and Ifo-2 are facing higherlevels of health problems and malnutrition than the more established Hagadera camp.

- Poor hygiene and sanitation are likely to have contributed to higher levels of diarrhoea inyoung children in both Ifo-2 and Kambioos. The inadequate feeding practices duringepisodes of diarrhoea place these children at greater risk of deteriorating quicker intosevere acute malnutrition.


As a result of the on-going threat of attacks and abductions of humanitarian aid workers andpolice throughout the camps in 2012, IPs have faced significant difficulty in maintaining andeffectively scaling up nutrition programmes. When programmes are not completely operational orare operated by staff that are not fully qualified, the effectiveness of treatment programmes falls.

Programme coverage in young children, 6-59 months

Selective feeding programmesGenerally, coverage results from a standard nutrition survey should be used with caution due tothe small sample size obtained. Coverage results for the selective feeding programmes (OTP andTSFP) ranged from 5.3% to 46.2% for OTP and 9.8% - 17.1% for TSFP, based on all admissioncriteria. With a target of >90% for coverage these results are poor. Coverage was also calculatedbased on MUAC and oedema only, as this is the current screening tool used across all camps inDadaab. Whilst the coverage based on MUAC/oedema was higher and ranged from 0.0% to61.9% for OTP and 26.1% to 36.1% for TSFP, they also fall well below the >90% target.

Vaccination, vitamin A supplementation and deworming coverageThe coverage of measles vaccination may have improved slightly compared to last year inHagadera, both with card (42.7% (2011) to 50.9% (2012)) and by card or recall (89.2% (2011) to97.9% (2012)). Ifo-2 and Kambioos had much lower confirmation by card, 22.3% and 10.4%respectively. Coverage based on either card or recall was much higher at 83.4% in Ifo-2 and96.6% in Kambioos. With a target of >95% it is clear that more needs to be done to ensureadequate vaccination coverage across all camps. The significant gap between confirmation bycard, and card or recall, can be interpreted as either the children have not received thevaccination and the caregiver is possibly recalling something different, the card was not taken forthe vaccination to be recorded, or many children do not have a card.

A similar difference was seen for Vitamin A supplementation confirmed by card versus card orrecall; 5.8% in Kambioos (94.8% by card or recall) and 18.1% in Ifo-2 (97.9% with card or recall).Again, Hagadera showed a higher coverage which had also increased from the previous nutritionsurvey – from 20.9% to 40.3% this year with confirmation by card, and increased from 86.8% to96.3% by card or recall.

Coverage of deworming was only asked by recall, as it was understood that there was noconsistent documenting of the deworming during the recent Malezi Bora campaign. Dewormingcoverage was high in Hagadera (95.9%) and Kambioos (83.7%) but lower in Ifo-2 (62.4%). Thislow result for Ifo-2 leads us to question the accuracy of recall because it contrasts strongly withthe coverage of deworming during Malezi Bora in May 2012.

Good coverage of the full PENTA vaccination was seen in Hagadera – 81.9% (increase from39.0% in 2011), yet it was much lower in Ifo-2 – 57.9% and Kambioos – 52.3%. This wasconfirmed by card only and as Ifo-2 and Kambioos are new camps since the last survey, it issomewhat encouraging that at least half of the children in Ifo-2 and Kambioos have EPI / healthcards.

These results demonstrate that there needs to be an improved supply of EPI/Road to Healthcards and emphasis placed on the importance of recording information on the card. Moreover, allIPs should work to record vitamin A supplementation and administration of deworming treatmenton the card, so the children are not placed at risk of over-supplementation for example,particularly if they are or have recently been enrolled in a selective feeding programme. All staff,incentive staff, volunteers and community leaders should be given a consistent and strongmessage to encourage all families and caregivers to keep the card safe and to take it whenattending any health-related service or campaign.

Anaemia in young children and women


Levels of anaemia amongst children 6-59 months remain high (i.e. >40%) in all three camps;Kambioos - 50.7% (45.3 – 56.0), Ifo-2 - 45.5% and Hagadera - 44.5% (39.2 – 50.0), the latter notseeing any significant improvement since the previous survey, when anaemia was at 45.3% (40.4– 50.2). This is surprising considering that the blanket supplementary feeding programme wasoperated uninterrupted by WFP since the last survey and that ACF-Spain has also beenconducting Phase 1 of their IYCF intervention in all camps. Such results do, however, suggest apossible problem with the effectiveness of these programmes, a possibility that is supported bythe low coverage measured for the BSFP. Additionally, non-nutritional causes may be acontributing factor to these high levels of anaemia, for example, intestinal worms andhaemoglobinopathies.

There was a suggestion of a decrease in anaemia levels among non-pregnant women between15 - 49 years in Hagadera, from 43.3% in 2011 to 38.8% in this survey; however this was notstatistically significant. Anaemia levels amongst non-pregnant women (15-49 years) in Ifo-2 andKambioos were lower at 33.3% and 32.0% respectively. All three camps are classified assuffering from a medium level of anaemia for this population group.

Programme coverage in womenCoverage of ANC programmes were high in Hagadera - 96.0% (95% CI 87.5 – 100.0) andKambioos - 96.6% (95% CI 91.3 – 100.0) shown by confirmation with card whereas Ifo-2 waslower at 72.6% (95% CI 59.3 – 87.9). The only results for which a trend could be seen over timewas Hagadera, where coverage more than doubled (to 96.0%) from 42.4% (95% CI 19.9-64.9) in2011. The proportion of women enrolled in the ANC programme that stated they are currentlyreceiving iron-folic acid pills followed suit in Hagadera; 96.0% (95% CI 87.5 – 100). However theproportion of women receiving iron-folic acid pills in Kambioos was more than 10% lower thanenrolments at 86.2% (95% CI 72.4 – 100.0) and in Ifo-2 only slightly lower at 70.8% (95% CI 56.7– 84.9). This may be due to women receiving the supplement, but not actually taking it, lack ofsupplies in the health posts or lack of attendance to receive the pills even if the woman isenrolled. Distribution of the supplement is not enough to ensure levels of anaemia improve; thereneeds to be health education and two way dialogue utilising behaviour change communicationstrategies with the women to ensure the programme is effective.

When confirmed by card only, the proportion of women who received Vitamin A supplementationwas low in all three camps, ranging from 39.5% to 48.5%. However, when assessed using cardor recall it was much higher; between 84.9% and 94.1%. This probably means that not allwomen take their card when visiting health posts and hospitals or they don’t have a card becauseit is likely that a woman would remember if she herself received a supplement within the past 6months since giving birth.

IYCF indicatorsLevels of anaemia in children 6 – 23 months are very high; higher than in children 6-59 monthsold and they have not changed since the survey in 2011. The prevalence of anaemia in Ifo-2 is atthe same level as Hagadera, and in Kambioos it is a little higher at 66.5%. Severe anaemia hasincreased since the last survey and was three times higher in Hagadera (1.5%) than bothKambioos and Ifo-2 (0.5%). Ifo-2 revealed higher levels of mild anaemia (35.5%) than moderateanaemia (27.3%). These very high levels of anaemia in infants less than 23 months may be dueto infants not receiving the blanket supplementary food that is intended and reportedly distributed,and/or Infant and Young child feeding and care practises compromising their ability to absorb iron(and of course other nutrients), poor dietary diversity and non-nutritional factors such as intestinalworms and haemoglobinopathies.

Although there have been some improvements in infant feeding practices, some indicatorsremain poor. Whilst the proportion of children ever breastfed was above 90% in all three camps,surprisingly, Hagadera saw similar levels between 2011 (99.3%) and 2012 (93.4%). This isdifficult to interpret as the rate of infants being given formula dropped from 22.0% (95% CI 15.2 -28.7) in 2011 to 1.9% (0.0 – 3.8) in this survey, which is statistically significant. Continued


breastfeeding at one year of age has remained stable at around 63% and at two years may haveimproved from 13.3% in 2011 to 22.9% (95% CI 5.7 – 40.0). Exclusive breast feeding of infantsunder 6 months in Hagadera improved substantially, from 47.1% (95% CI 35.9-58.4) to 83.0%(95% CI 73.4 – 92.6) (p<0.05), as did the early initiation of breastfeeding from 83.3% (77.3-89.3)to 96.0% (91.9 – 100.0). In contrast, Ifo-2 saw lower levels of exclusive breastfeeding under-6months (72.7%) and also early initiation of breastfeeding (68.1%), which is of concern. However,had the highest prevalence of continued breastfeeding at 1 year (78.4%), while Kambioos hadthe lowest level (57.1%).

It is alarming that only 20.0% (95% CI 0.0 – 46.1) of infants in Kambioos and 50.0% (95% CI 30.6– 69.4) in Ifo-2 had had solid/semi-solid/soft food introduced by 9 months of age, as it becomesimpossible to meet their nutrition needs from breastmilk or fluids alone and places these childrenat increased risk of malnutrition from an early age. In Hagadera, the introduction of solidschanged from 83.3% (95% CI 72.6-94.1) in 2011 to 66.7% (95% CI 45.7 – 87.6) in 2012,however, this was not statistically significant. Besides needing to meet nutritional requirements, itis an important developmental milestone to begin eating solid/semi-solid/soft foods at around 6months.

Between 3.1% (95% CI 0.2 – 6.0) in Hagadera (which is down from 8.1% last survey) and 4.3%of children in Kambioos are bottle fed, placing them at risk of illness due to the ease ofcontamination in such settings. Worrying levels of other liquids being given to children wererevealed; between 32.1% of children 0-23 months in Kambioos and 40.3% in Ifo-2 are beinggiven tea or coffee, both of which inhibit the absorption of iron, thus increasing their risk of irondeficiency and anaemia. Whilst this may be culturally acceptable, it is not appropriate for infantsto receive these other fluids; as milk and milk alternatives, as another example, given before 12months of age increases the risk of colitis (bloody diarrhoea), and the survey indicated thatbetween 13.9% (in Kambioos) and 21.5% (in Hagadera) of children less than 12 months areconsuming animal and other milks.

The proportion of children given water or sugar water before 6 months of age when they shouldnot receive any fluids other than breastmilk ranged from 1.7% in Kambioos to 26.1% in Ifo-2,another contributing factor to diarrhoeal illness in infants less than 6 months.

Whilst the reported prevalence of diarrhoea in infants less than 24 months varied between thethree camps, from 4.7% in Hagadera to 16.7% in Ifo-2, the most disconcerting behaviour relatedto this were the low levels of continued feeding during episodes of diarrhoea; ranging from analarming 0.0% in Kambioos to only 46.6% in Hagadera, which saw no improvement since theprevious survey in 2011 (47.6% (95% CI 33.3 - 61.9)). Not continuing to feed any person during adiarrhoeal illness usually results in some weight loss, but to feed an infant inadequately meansthey are more likely to become malnourished or further malnourished much quicker. Feedingduring diarrhoea also helps to shorten the episode and promotes recovery.

It is clear that significant and continued effort on awareness raising and capacity building forinfant and young child feeding and care practises is needed in all the camps.

Food security indicatorsThe majority of households surveyed had a ration card from 98.2% (95% CI 94.6 – 100.0) inKambioos to 100.0% in Ifo-2, yet Kambioos (18.0%) and Hagadera (6.7%) camps report to behosting unregistered household members. This question regarding hosting unregisteredhousehold members was not asked in Ifo-2 as it was the first survey and was the prompt forincorporating this question for the following surveys.

Despite receiving the general food ration, the average length it lasted ranged from 9.7 days inKambioos to 12.6 days in Hagadera, with more than nine out of ten households in both Kambioosand Ifo-2 stating that the ration did not last for the 15 days until the next distribution. In Hagaderaless than 40% of households surveyed are food secure as 61.8% reported that the ration did not


last 15 days.

In Hagadera and Kambioos, 57.7% and 77.1% of households respectively sold or exchangedsome of their food ration, whereas in Ifo-2 this was lower at 29.0%. Although households in Ifo-2,where the first survey was conducted, may have reported selling part of their ration had theteams probed the respondents further. Teams were instructed in the following two surveys toprobe more extensively as it was suspected that this response option was being underreported.

The main items purchased or exchanged were milk and sugar in Kambioos (>90% each); milk(86.5%) followed by sugar (59.4%) in Hagadera. Across all camps, the majority of householdscoped with this shortfall by borrowing or receiving credit from friends/family/neighbours, withresults ranging from 79.3% to 93.4% across the three camps which is by far the most significantcoping mechanism. It is concerning to see that ‘eating less food’ and ‘eating less often’ were alsoreported in Kambioos as very few had the means to buy more food.

WASH indicatorsDespite the relocation of many refugees to both Ifo-2 and Kambioos since the 2011 survey, theWASH situation remains problematic in all three camps, hence a significant scale up of WASHfacilities in these two new camps is required during the on-going relocation of refugees fromHagadera to Kambioos

It is worrying that in Hagadera 31.0% (95% CI 18.7 – 44.4) and in Ifo-2 11.8% (95% CI 4.4 –19.1) of households are using an unimproved toilet, increasing the risk of communicablediseases. Last year in Hagadera the proportion of families using an unimproved toilet was 1.7%(95% CI 0.2-3.3), so the 2012 results indicate a significant increase. Furthermore, 30.0% ofhouseholds in Ifo-2 and 64.9% of households in Kambioos reported sharing their toilet with atleast two other households (three households sharing in total). With the average household sizeof 6.5 persons, this suggests the SPHERE and UNHCR standard of 1 toilet per 20 persons is notbeing met for many refugees across the camps. As communal toilets are much more difficult tokeep clean, particularly with increasing numbers of people using them, this is likely to havecontributed to the spread of the recent Hepatitis E outbreak in Ifo-2 and also the higherprevalence of diarrhoea amongst both children 6 – 59 months and infants 0-23 months reportedin Ifo-2 and Kambioos camps.

According to the responses regarding the availability of enough water containers to collect water,there is an urgent need to procure and distribute appropriate water containers to households inboth Ifo-2 and Kambioos. Again, the outbreak of Hepatitis E appeared to be localised to Ifo-2where only 3.7% of households reported have enough water containers to collect water. InKambioos the response rate of 22.5% having sufficient water containers, demonstrates the needto provide more containers. Both Ifo-2 and Kambioos surveys revealed much higher levels ofdiarrhoea amongst children, which is often associated with poor hygiene practices, inadequatesanitation and insufficient water.

When asked if they were satisfied with the drinking water supply, in these three camps, between84.8% (in Ifo-2) - 98.9% (in Kambioos) of households responded positively. The reasons given fordis-satisfaction in Ifo-2 was predominately that the ‘amount is not enough’, which may be relatedmore to the ability to collect enough water (i.e. without enough water containers), rather than thequantity and continuity of water supply there. For Hagadera, the main reason was the ‘longqueues’ at the water taps which indicates the camp remains over-crowded and either more waterdistribution point are needed and/or the relocation of refugees from Hagadera needs to beexpedited.

The provision of soap has improved since the survey in 2011. In all three surveys this year, morethan 90% of households answered ‘yes’ to receiving soap in the two distribution cycles leading upto the survey. Kambioos and Hagadera reached 98.8% and 98.6% respectively, a verysignificant improvement from the 2.0% found in the 2011 survey in Hagadera.


Despite this, a major barrier to utilising the soap distributed to households is the availability ofadequate water to be able to wash hands before eating and after using the toilet. With morewater containers available and sensitisation messages regarding the importance of hand-washing, particularly in young children, it is likely that the spread of disease and incidence ofdiarrhoea could be decreased.

CONCLUSION

Despite Dadaab being a difficult environment in which to conduct the nutrition surveys in 2012,quality data was successfully collected for Ifo-2, Hagadera, and Kambioos camps, of which twoare newly opened since the last survey. A drop was seen in the number of refugees arriving fromearly in 2012, but despite this the health and nutrition status remains fragile and sub-standard,the reasons for which include; the weakened state and poor condition in which the new refugeesarrived, having fled from a serious drought; the large scale of the influx and the time taken toscale up programmes to meet the increased needs across the Dadaab complex as a whole; andadditional barriers and interruption to service delivery resulting from on-going insecurity since latein 2011.

While the under-five mortality and crude mortality rates in Kambioos were within the acceptablerange, improved awareness regarding services and supports is needed, particularly withinKambioos and Ifo-2, which are worse off than Hagadera. Although malnutrition rates haveimproved somewhat since the previous survey, the most significant contributing factors to on-going high levels of malnutrition are poor infant and young child care practices.

Further measures are needed to improve the detection of malnutrition cases early, as the higherrates of oedema in each camp and significant rates of SAM and GAM in two camps remain abovethe emergency levels for malnutrition increasing the mortality risk. Growth monitoring for allchildren less than 36 months may be one approach to more effective screening, while capacitybuilding of all health and nutrition staff should be an on-going approach.

Education and sensitisation for both mothers and fathers of young children should be conductedto improve infant and young child feeding and care practices; focusing on exclusive breast-feeding until 6 months, timely introduction of solids and complementary foods. Family planningshould continue to be addressed in a culturally appropriate manner to increase the gap betweenchildren which will help to improve maternal nutrition status.

In Ifo-2 and Kambioos particularly, hygiene promotion activities must be scaled up and theconstruction of latrines needs to be continued, so that less households are sharing facilities orusing no latrine at all.

Above all capacity building amongst the refugee population (incorporating behaviour changecommunication strategies) should be prioritised with consideration of the sustained insecurity inthe region, and to help equip the population for the future.

It is worth remembering that despite some improvement in malnutrition, the target for acceptablelevels of GAM is <5% according to WHO (using Weight-for-Height z-scores). Time, resourcesand an on-going commitment are required from all sectors and agencies to achieve this in thefuture.


REFERENCES

GoK. Kenya National Guidelines for integrated management of acute malnutrition, 2009.

SMART. Standardised Monitoring and Assessment of Relief and Transitions, Version 1 April 2006.

The East African, “Agencies reject plan to relocate refugees”, August 4th

2012

The Economist, “Somalia and the Shabaab; it’s not over yet”, October 6th

2012

UNHCR Health Information System (HIS) http://data.unhcr.org/horn-of-africa/country.php?id=110

UNHCR Strategic Plan for Nutrition and Food Security 2008-2012, Geneva Switzerland.

UNHCR Dadaab-Alinjugur Situation Report 15-31st

August 2012

UNHCR. Dadaab Nutrition Survey Report, August 2009.

UNHCR. Dadaab Nutrition Survey Report, August 2010.

UNHCR. Dadaab Nutrition Survey Report, August 2011

UNHCR Somalia: Kismayo PMT report, Sept 2012

UNHCR / ENN / UCL. UNHCR Standardised Expanded Nutrition Survey Guidelines for RefugeePopulations: A practical step-by-step guide, Version 1.3 March 2012.

UNHCR / GIZ / IRC. Report on the findings of a mass MUAC screening carried out in Ifo, Ifo-2, Dagahaley,Hagadera and Kambioos camps from 26

thto 30

thMarch 2012.

UNHCR: Malezi Bora Consolidated Report May 2012.

UNICEF / WHO. Indicators for assessing infant and young child feeding practices, 2007.

WHO. The management of nutrition in major emergencies, 2000.

http://data.unhcr.org/horn-of-africa/country.php?id=110


Appendix 1 - Names of contributors

Data collection teams

Ifo 2 Camp Hagadera Camp Kambioos campTechnical assistance

from GIZ and IRC

Team members Team members Team Members

1 Kevin Mutegi 1 Noor Shafe 1 Fatuma Mohamed 1 Mohamed Abdullahi Musa

2 Yakub Kune 2 Hassan Abdullahi 2 Muhiyadin Ali 2 Hassan Mukhtar Mohamed

3 Abdiweli Maah 3 Abshiro Noor 3 Musa Garas 3 Caroline Gitonga (ADEO)

4 Margaret Muli 4 Ahmed Osman 4 Abdullahi Aden 4 Ojuw Omod Amead

5 Mohamed Mahat Elmoge 5 Abdirashid Mohamed 5 Dakane Ugas 5 Isse Abdi Farah

6 Abdinoor Mohamed 6 Ahmed Noor Osman 6 Abdullahi Idle 6 Mohamed Ali Hud

7 Fugicha Arero 7 Abshiro Noor Ali. 7 Mowlid Billow 7 Abdimahat Hassan

8 Judith Ogugu 8 Osman Mohammed Osman 8 Yussuf Ahmed 8 Hussein Abdi Yarow

9 Irene Njoki 9 Abdi Ahmed Mohammed 9 Mowlid Isaack 9 Fatumo Omar Shiekh

10 Abdullahi Ali Hirabey 10 Abubakar Duhul 10 Bishar Mohamed 10 Okugu Ojulu Oidumo

11 Noor Olow Aden 11 Abdullahi Salat Mahamud 11 Cyard Jamac 11 Hussein Ibrahim Ali

12 Gediya Mohamed Ali 12 Siyad Abdi Aress 12 Adan Ali Omar 12 Mohamed Ali Zubeir

13 Amin Abdi Rage 13 Mohammed Musa Hassan 13 Mohamed Adan

14 Bishar Mohamed Hassan 14 Issack Hussein 14 Abdirisack Hassan

15 Abdirizah Abdi Hussein 15 Hani Abdiqadir 15 Adhan Hassan

16 Hared Abdi Ali 16 Aden Osman Ali 16 Farah Issack Jamac

17 Abdirahman Mohamed Aden 17 Abdi Hassan Ahmed 17 Abdikadir Noor

18 Hussein Mohamed Abubakar 18 Abdirahman Mohammed 18 Reys Mohamed

19 Mohamed Issack Aden 19 Mohammed Ahmed Hiddig 19 Mohamed deq Ahmed

20 Ahmed Weli Abdi Muhamed 20 Rashid Abdi Omar 20 Dubow Abdullahi

21 Abshir Hassan Abdirahman 21 Mohammed Ali Mohamed 21 Ismail Mohamed Salah

22 Hawo Salat Yussuf 22 Amina Abdullahi

23 Farhio Mohamed Omar

24 Sadio Hassan Abdi

25 Ifrah Mohammed

Supervisors Supervisors Supervisors

1 Alisia Osiro 1 Sirat Abdullahi Amin 1 Amina Mohamed

2 Mulkhi Hussein 2 Joshua Rutto 2 Kilonzo Daniel

3 Dr. Nailah Kassim 3 3 Dr Jojo Cangao


Survey coordination / team supervision / technical team

UNHCR

Mary Koech

Dr John Burton

Edna Moturi

Geoffrey Luttah

Allison Oman

UCL

Andrew Seal

Jo McElhinney

Laure Belotti

CartONG

Sandra Sudhoff

ADEO

Mary Orwenyo

Margaret Ouma

Hassan Abdullahi

WFP

Colin Bulleti

UNICEF

Francis Kidake

Data verification assistants

Michael Ochieng

James Mbai

Alisia Osiro

Kilonzo Daniel

Mohammed Doumbia

David Okwiri

Data analysis / report writing

Jo McElhinney

Andrew Seal

Additional thanks to the following people who provided information / assistance / feedback:

Evans Njoroge Miruru and Ally Said


Appendix 2

HAGADERA

Standard/Reference used for z-score calculation: WHO standards 2006

Overall data quality

Criteria Flags* Unit Excel. Good Accept Problematic Score

Missing/Flagged data Incl % 0-2.5 >2.5-5.0 >5.0-10 >10(% of in-range subjects) 0 5 10 20 0 (0.5 %)Overall Sex ratio Incl p >0.1 >0.05 >0.001 <0.000(Significant chi square) 0 2 4 10 0 (p=0.806)Overall Age distrib Incl p >0.1 >0.05 >0.001 <0.000(Significant chi square) 0 2 4 10 0 (p=0.227)Dig pref score - weight Incl # 0-5 5-10 10-20 > 20

0 2 4 10 0 (3)Dig pref score - height Incl # 0-5 5-10 10-20 > 20

0 2 4 10 4 (11)Standard Dev WHZ Excl SD <1.1 <1.15 <1.20 >1.20

0 2 6 20 2 (1.13)Skewness WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0

0 1 3 5 0 (0.01)Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0

0 1 3 5 0 (0.94)Poisson dist WHZ-2 Excl p >0.05 >0.01 >0.001 <0.000

0 1 3 5 0 (p=0.637)Timing Excl Not determined yet

0 1 3 5OVERALL SCORE WHZ = 0-5 5-10 10-15 >15 6 %

At the moment the overall score of this survey is 6 %, this is good.

Missing data:HEIGHT: Line=280/ID=2, Line=367/ID=1, Line=448/ID=1

There were no duplicate entries detected. Percentage of children with no exact birthday: 37 % Percentage of values flagged with SMART flags: WHZ: 0.5 %, HAZ: 3.5 %, WAZ: 1.0 % Age ratio of 6-29 months to 30-59 months: 0.95 (The value should be around 1.0).

Statistical evaluation of sex and age ratios (using Chi squared statistic):

Age cat. mo. boys girls total ratio boys/girls-------------------------------------------------------------------------------------6 to 17 12 64/70.3 (0.9) 72/68.9 (1.0) 136/139.2 (1.0) 0.8918 to 29 12 74/68.5 (1.1) 82/67.2 (1.2) 156/135.7 (1.1) 0.9030 to 41 12 64/66.4 (1.0) 65/65.1 (1.0) 129/131.6 (1.0) 0.9842 to 53 12 65/65.4 (1.0) 47/64.1 (0.7) 112/129.5 (0.9) 1.3854 to 59 6 36/32.3 (1.1) 31/31.7 (1.0) 67/64.0 (1.0) 1.16-------------------------------------------------------------------------------------6 to 59 54 303/300.0 (1.0) 297/300.0 (1.0) 1.02

Overall sex ratio: p-value = 0.806 (boys and girls equally represented)Overall age distribution: p-value = 0.227 (as expected)

Overall sex/age distribution: p-value = 0.050 (as expected)


IFO-2Standard/Reference used for z-score calculation: WHO standards 2006







0 1 3 5 0 (0.06)Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0




At the moment the overall score of this survey is 10 %, this is good.

There were no duplicate entries detected.Percentage of children with no exact birthday: 51 %Percentage of values flagged with SMART flags:WHZ: 1.1 %, HAZ: 5.2 %, WAZ: 1.6 %Age ratio of 6-29 months to 30-59 months: 0.75 (The value should be around 1.0).



Overall sex ratio: p-value = 0.426 (boys and girls equally represented)Overall age distribution: p-value = 0.345 (as expected)Overall sex/age distribution: p-value = 0.091 (as expected)

Digit preference Height:Digit .0 : ####################Digit .1 : ######################################Digit .2 : ####################################################Digit .3 : ###################################################Digit .4 : ######################################Digit .5 : ##########################Digit .6 : ################################Digit .7 : ############################Digit .8 : ##############Digit .9 : ################

Digit Preference Score: 13


KAMBIOOSStandard/Reference used for z-score calculation: WHO standards 2006







0 1 3 5 0 (-0.29)Kurtosis WHZ Excl # <±1.0 <±2.0 <±3.0 >±3.0




At the moment the overall score of this survey is 28 %, this is problematic.

There were no duplicate entries detected. Percentage of children with no exact birthday: 81 % Percentage of values flagged with SMART flags:WHZ: 1.0 %, HAZ: 5.2 %, WAZ: 1.8 % Age ratio of 6-29 months to 30-59 months: 0.87 (The value should be around 1.0).

. no exclusion exclusion from exclusion from. reference mean observed mean. (WHO flags) (SMART flags)WHZStandard Deviation SD: 1.34 1.26 1.23(The SD should be between 0.8 and 1.2)Prevalence (< -2)observed: 17.0% 16.4% 16.5%calculated with current SD: 20.7% 18.4% 18.2%calculated with a SD of 1: 13.7% 12.9% 13.2%



Overall sex ratio: p-value = 0.037 (significant excess of boys)Overall age distribution: p-value = 0.537 (as expected)Overall sex/age distribution: p-value = 0.049 (significant difference)


Appendix 3 - Interpretation of the key quality criteria from the SMART plausibility reportson anthropometric data from Hagadera, Ifo-2, and Kambioos

The Plausibility reports are generated by ENA for SMART software after entering a data set and provide a variety ofstatistical checks to indicate the quality of the weight-for-height z-scores anthropometric data. A ‘problematic’ scoreshould lead to a careful examination of the anthropometric data but, by itself, does not necessarily mean that the datais of poor quality. A summary of the results from the Plausibility Reports is given below with recommendations for futuresurveys where appropriate.

SMART specifies that missing or flagged values should not exceed 5-10%. Missing or Flagged weight-for-heightdata from all camps, ranged from 0.5 – 1.1%, whilst two camps contained 5.2% of height-for-age scores flagged.

The sex ratio in two of three camps data sets was acceptable; however Kambioos revealed an excess of boysselected. Although the boys/girls ratio sat at 1.19 for Kambioos, which falls within the acceptable range of 0.8-1.2,the p value of 0.037 indicates there was a significant difference.

No duplicate entries were detected in any data set, which is attributed to effective data cleaning techniques. In one set of results only (Hagadera), three height measurements were missing and listed in the Plausibility reports.

These were children with disabilities who were unable to have their height accurately measured. This wasconfirmed by the supervisor and checked with the survey manager at the time of visiting each of those threechildren.

Different age groups should usually be equally represented. The overall age distribution was unbalanced in the twoof the camps, (Ifo-2: 0.75 age-ratio and Kambioos: 0.81 age-ratio), with the older children 30 – 59 months beingover-represented. Hagadera showed an age-ratio of 0.95 indicating that the younger children 6 – 29m were asequally represented as the older children 30-59 m. These differences correlate with the percentage of records withproof of age documentation; Kambioos - 81%, Ifo-2 - 51%, Hagadera - 27% had birth certificates. This is arelatively common bias created when the events calendar is used to determine age due to the difficulty in precision;for example caregivers tend to recall best the birth date of smaller children more accurately than older children.Despite the provision of training, additional efforts should be made in future surveys to better estimate the age ofthe children using the local event calendar.

In all surveys, there was less digit preference for weight measurements as compared to height measurements dueto the use of the electronic scales. All three surveys were penalised for digit preference of height measurements,but remained acceptable. Additional efforts should be made in future surveys to limit digit preference for the heightmeasurements.

The standard deviation (SD) of weight-for-height z-scores should be less than 1.2 according to SMARTrecommendations. As shown in the Tables below, in all four surveys, the SD ranged from the lowest of 1.13 inHagadera to the highest of 1.23 in Kambioos when using the WHO Standards 2006 and hence Kambioos was theonly survey to receive the maximum penalty of 20 points, which pushed the overall plausibility above 20%. Whenapplying the NCHS 1977 Reference, none received the penalty as seen by the SD all being closer to 1.0.

The ‘problematic scores’ reported here for the SDs can most likely be attributed to the following: 1) the SD tends tobe wider when using WHO Standards 2006 as compared to NCHS 1977 Reference; 2) some imprecision in heightmeasurements – all surveys were penalised for this; 3)

Table 136 Summary table of mean z-score, design effect, and excluded subjects for the weight-for-height index usingboth reference populations - Ifo-2 camp (Oct 2012)

Reference population n Mean z-scores± SD

Design Effect (z-score < -2)


z-scores outof range

WHO Standards 2006 617 -0.84 ± 1.17 1.00 6 7

NCHS Reference 1977 619 -1.00 ± 0.97 1.04 5 6

*contains for WHZ and WAZ the children with oedema.

Table 137 Summary table of mean z-score, design effect and excluded subjects for the weight-for-height index usingboth reference populations - Hagadera camp (Sept 2012)

Indicator n Mean z-scores ± SD

Design Effect (z-score < -2)



WHO Standards 2006 591 -0.66 ± 1.13 1.00 6 3

NCHS Reference 1977 590 -0.86 ± 0.96 1.58 6 4

* contains for WHZ and WAZ the children with oedema.

Table 138 Summary table of mean z-score, design effect and excluded subjects for the weight-for-height indexusing both reference populations - Kambioos camp (Sept 2012)

Indicator n Mean z-scores ± SD

DesignEffect (z-

score < -2)


z-scores outof range

WHO Standards 2006 589 -0.88 ± 1.23 1.00 4 6

NCHS Reference 1977 592 -1.05 ± 1.05 1.11 4 3* contains for WHZ and WAZ the children with oedema.


Appendix 4 - Assignment of clusters

HAGADERA

Block Cluster Day

HAG N-4 1 1

HAG K-10 7 1

HAG K-9 17 1

HAG M-1 23 1

HAG K-7 26 1

HAG L-8 2 2

HAG A-10 15 2

HAG A-4 16 2

HAG J-10 25 2

HAG A-1 30 2

HAG H-5 3 3

HAG G-9 5 3

HAG L-5 8 3

HAG L-7 14 3

HAG M-6 21 3

HAG F-5 10 4

HAG C-4 20 4

HAG B-5 22 4

HAG B-2 24 4

HAG F-1 27 4

HAG C-10 4 5

HAG B-9 9 5

HAG I-1 11 5

HAG C-7 12 5

HAG H-1 18 5

HAG E-7 6 6

HAG E-4 13 6

HAG D-3 19 6

HAG C-1 28 6

HAG D-1 29 6

HAG J-2 RC

HAG F-3 RC

HAG I-11 RC

HAG O-1 RC

Total population used: 138,942


KAMBIOOS

Block Cluster Day

Kam 09-E 3 1

Kam 09-G 8 1

Kam 09-G 9 1

Kam 09-F 10 1

Kam 09-B 24 1

Kam 09-D 5 2

Kam 09-C 16 2

Kam 09-C 17 2

Kam 09-A 22 2

Kam 09-A 23 2

Kam 08-C 4 3

Kam 08-A 29 3

Kam 08-A 30 3

Kam 10-E 11 3

Kam 10-E 12 3

Kam 10-B 6 4

Kam 10-B 7 4

Kam 10-C 13 4

Kam 10-D 25 4

Kam 10-D 26 4

Kam 10-F 14 5

Kam 10-F 15 5

Kam 10-G 18 5

Kam 10-G 19 5

Kam 08-G 1 5

Kam 08-F 2 6

Kam 10-A 20 6

Kam 10-A 21 6

Kam 08-B 27 6

Kam 08-B 28 6

Kam 09-F RC -

Kam 09-B RC -

Kam 10-C RC -

Kam 08-B RC -

Total population used: 14,205


IFO-2

Block Cluster Day #

IFO3 M-01 14 1

IFO3 R-05 23 1

IFO3 R-03 24 1

IFO3 T-06 28 1

IFO3 U-01 29 1

IFO3 N-02 18 2

IFO3 N-05 19 2

IFO3 S-01 25 2

IFO3 S-03 26 2

IFO3 T-02 27 2

IFO2 I-03 8 3

IFO2 I-04 9 3

IFO3 Q-02 20 3

IFO3 Q-01 21 3

IFO3 Q-03 22 3

IFO2 D-01 1 4

IFO2 D-07 2 4

IFO2 H-06 7 4

IFO2 J-05 10 4

IFO2 L-04 13 4

IFO2 K-01 11 5

IFO2 K-02 12 5

IFO3 M-03 15 5

IFO3 M-06 16 5

IFO3 M-05 17 5

IFO2 E-02 3 6

IFO2 F-06 4 6

IFO2 G-03 5 6

IFO2 G-04 6 6

IFO3 U-06 30 6

IFO2 H-01 RC -

IFO2 I-06 RC -

IFO3 S-02 RC -

IFO3 U-03 RC -

Total population used: 69, 091


Appendix 5 - Maps of Dadaab camps


Appendix 6 - Plan of Kambioos Block


Appendix 7 - Survey questionnaires


1. Dadaab Nutrition Survey, September 2012, Household Questionnaire

Date (dd/mm): |______|_____|/|_____|_____|/2012 Cluster Number: |_____|_____| Team Number: |_____|

Block Code / Number: |_____|_____|_____|Camp/Survey Number:1=IFO-2, 2=DAG, 3=KAM, 4=HAG, 5=IFO |_____|

HH1 HH2 HH3 HH4 HH5 HH6 HH7 HH8 HH9 HH10 HH11

HHNumber

Consent

1=yes2=no3=absent

When didyourhouseholdarrive inthecamps?

How manypeople live inthishousehold?

Has yourhouseholdbeenregistered?

1 = yes2 = no99 = Don’tKnow

Does yourhouseholdhave arationcard?

1= yesGO TO HH7

2 = noGO TO HH6

Why do younot have aration card?

USE CODESBELOW

NOW GO TOHH11

IF HH5 IS YES:How many daysdid the foodfrom the lastcycle of thegeneral rationlast?(number of days)

IF ANSWER IS15 DAYS ORMOREGO TO HH11

IF HH7 IS <15DAYS: Whatis the mainreason thegeneralration did notlast until thenextdistribution?

SELECT ONEUSE CODESBELOW

If food is soldorexchanged,what do youexchange itfor?

RECORD ALLRESPONSES

USE CODESBELOW

IF HH7 IS <15DAYS: Whatwas the mostimportant thingyou did to fillthe gap?

SELECT ONEUSE CODESBELOW

Has insecurity orclosure of healthcentres preventedanyone in yourhousehold fromvisiting a healthcentre in the last 2months?1 = yes2 = no3 = didn’t need to go

01

02

03

04

05

06

07

08

09

10

11

12

CODES:HH2: 1=July-September 2012, 2=April-June 2012, 3=January-March 2012, 4=October-December 2011, 5=Arrived before October 2011 or born in camps.HH6: 1=Not given one at registration, 2=Lost card, 3=traded, 98=Other.HH8: 1=New arrivals joined, 2=Shared with kin, 3=Ration not big enough, 4=Some sold or exchanged, 5=Gave to livestock, 6=Lost due to theft, 7=Lost due to poor storage, 98=Other.HH9: 1=Food not sold/exchanged, 2=Meat, 3=Sugar, 4=Milk, 5=Rice/pasta/potatoes, 6=Vegetables, 7=Maize meal, 8=Firewood, 9=Shoes /clothing, 10=Scratch cards, 11=School fees,12=Food for livestock, 13=Bus fare / transport, 98=Other.H10: 1=Buy, 2=Borrow from neighbours or relatives / credit, 3=Donations from kin, 4=Reduce portion size, 5=Reduce number of meals per day, 98=Other.


Date (dd/mm): |______|_____|/|_____|_____|/2012 Cluster Number: |_____|_____| Team Number: |_____|

Block Code / Number: |_____|_____|_____|Camp/Survey Number:1=IFO-2, 2=DAG, 3=KAM, 4=HAG, 5=IFO |_____|

HH12 HH13 HH14 H15 HH16 HH17 HH18 HH19

HHNumber

Has insecuritypreventedanyone in yourhousehold fromcollecting thegeneral foodration in thelast 2 months?

1 = yes2 = no

Do you haveenough watercontainers tocollect waterfor all thehousehold?

1 = yes2 = no

What is the mainsource ofdrinking waterfor members ofyour household?

DO NOT READ THEANSWERS TO THEPARTICIPANT.

SELECT ONEONLY.

Are you satisfiedwith the drinkingwater supply?

THIS RELATES ONLYTO DRINKING WATER

SUPPLY.

1 = yesGO TO HH17

2 = no

Why are you notsatisfied with thewater supply?

1 = amount is notenough2 = long queue at thetap4 = water point is far5 = water tastes bad98 = other

What kind of toiletfacility does thishousehold use?DO NOT READ THEANSWERSTO THEPARTICIPANT

SELECT ONE ONLY.

How many householdsin total share thistoilet?

SELECT ONE ONLY.

1 = 12 = 23 = 3 or more4 = Pubic toilet (e.g. inmarket or clinic)

Did you receive soapwithin the last twodistribution cycles?

1 = yes2 = no3 = not registered

01

02

03

04

05

06

07

08

09

10

11

12

CODES:HH14: 1=Public tap/standpipe, 2=UNHCR Tanker, 3=Small water vendor, 4=Surface water (e.g. river, pond), 98=Other, 99=Don’t know.HH17: 1=Pour-flush to pit, 2=Simple pit latrine with floor/slab, 3=Pit latrine without floor/slab, 4=No facility, field, bush, plastic bag.


2. Dadaab Nutrition Survey, September 2012, Questionnaire for Women Aged 15-49 years

Date (dd/mm): |______|_____|/|_____|_____|/2012 Cluster Number: |_____|_____|Team Number: |_____|

Block Code / Number: |_____|_____|_____|

Camp/Survey Number:1=IFO-2, 2=DAG, 3=KAM, 4=HAG, 5=IFO |_____|

W1 W2 W3 W4 W5 W6 W7 W8 W9 W10 W11

WomanNo.

HHNo.

Consent

1=yes2=no3=absent

Age(years)

When did youarrive in thecamps?

IF ANSWER IS5 GO TO W5

USE CODESBELOW

Region oforigin

USECODESBELOW

Ethnicgroup

1=Somali2=SomaliBantu98=Other

Did you delivera baby in thelast 6 months?

1=yes alive

2=yes deadGO TO W9

3=noGO TO W9

Did you receivevitamin Asupplemen-tation sincedelivery?(SHOWCAPSULE)

1=yes card2=yes recall3=no or don’tknow

Are youbreast-feeding?

1 = yes2 = no

In the past 3months, sinceWorld RefugeeDay (June 20th),did you havejaundice(Cagaarshow)?

1=yes2=no99=don’t know

Are youpregnant?

1 = yesGO TO W13

2 = no

99=don’t know

Hb(g/dL)

1

2

3

4

5

6

7

8

9

10

11

12

CODES:

W3: 1=July-September 2012, 2=April-June 2012, 3=January-March 2012, 4=October-December 2011, 5=Arrived before October 2011 or born in camps.W4: 1 = Lower Juba, 2 = Middle Juba, 3 = Gedo, 4 = Bay, 5 = Bakool, 6 = Lower Shabelle, 7 = Middle Shabelle, 8 = Hiraan, 9 = Mogadishu / Banadir, 98= Other.


3. Dadaab Nutrition Survey, September 2012, Questionnaire for Children Aged 6-59 months

Date (dd/mm): |______|_____||_____|_____| 2012 Cluster Number: |_____|_____| Team Number: |_____|

Block Code / Number: |_____|_____|_____| Camp/Survey Number: 1=IFO-2, 2=DAG, 3=KAM, 4=HAG, 5=IFO |_____|

C1 C2 C3 C4 C5 C6 C7 C8 C9 C10

ChildNo.

HHNo.

Consent

1=yes2=no3=absent

Sex(m/f)

Birthdate(dd/mm/yyyy)

Age (months)

USEEVENTSCALENDAR

Weight(kg)

Height(cm)

Bilateraloedema(y/n)

MUAC(cm)

Weight takenwith clothes

1=yes2=no

IS CHILD ENROLED INNUTRITION PROGRAMME?

1 = OTP; 2 = TSFP;3 = Referred; 4 = Not needed

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22IF NO VALID AGE DOCUMENTATION IS AVAILABLE: DO NOT FILL IN C3, INSTEAD ESTIMATE AGE USING LOCAL EVENTS CALENDAR.C7 and C8: REFER TO HEALTH POST FOR MALNUTRITION IF NOT ALREADY ENROLED IN SFP /OTP: REFER IF OEDEMA OR IF MUAC<12.5 cm


C11 C12 C13 C14 C15 C16 C17 C18 C19 C20 C21 C22

ChildNo.

HHNo.

When did[name] arrivein the camps?

USE CODESBELOW

IF 5 GO TOC13

Regionof origin

USECODESBELOW

Ethnicgroup

1=Somali2=SomaliBantu98=Other

MeaslesVaccination

1=Yes with card2=Yes by recall3=No or don’tknow

PENTA1 orPENTA2 orPENTA3 withcard only

1=1 dose2=2 doses3=3 doses4=No PENTAor no card

Vit. A in past6 months(SHOWCAPSULE)

1=Yes card2=Yes recall3=No or don’tknow

Dewormed inpast 6months(SHOW PILL)

1=Yes recall2=No or don’tknow

Diarrhoea inlast 2 weeks(3 or moreloose orliquidstools/24hrs)

1 = yes2 = no99 = don’tknow

When[name] haddiarrhoeadid youfeed[name]:

1=less2= the same3=more4=no food

Hb(g/dL)

Childreferred forsevereanaemia

1=yes2=no

IS THIS CHILDAGED 6-23MONTHS?

1=yes2=no

IF NO STOPNOW

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

C11: 1=July-September 2012, 2=April-June 2012, 3=January-March 2012, 4=October-December 2011, 5=Arrived before October 2011 or born in camps.C12: 1 = Lower Juba, 2 = Middle Juba, 3 = Gedo, 4 = Bay, 5 = Bakool, 6 = Lower Shabelle, 7 = Middle Shabelle, 8 = Hiraan, 9 = Mogadishu / Banadir, 98= OtherREFERAL TO HEALTH POST FOR SEVERE ANAEMIA - C20: REFER IF Hb < 7.0 g/dL


4. Dadaab Nutrition Survey, September 2012, Questionnaire for Infants Aged 0-5 months

Date (dd/mm): |______|_____|/|_____|_____|/2012 Cluster Number: |_____|_____|Team Number: |_____|

Block Code / Number: |_____|_____|_____|

Camp/Survey Number:1=IFO-2, 2=DAG, 3=KAM, 4=HAG, 5=IFO |_____| Inclusion date:________/____04____/ 2012___

IN1 IN2 IN3 IN4 IN5 IN6 IN7 IN8 IN9 IN10

ChildNo.

HHNo.

Consent

1=yes2=no3=absent

Birthdate(dd/mm/yyyy)

Age(months)

Sex

1=male2=female

When did[name] arrive inthe camps?IF ANSWER IS 5GO TO IN7

USE CODESBELOW

Region oforigin

USE CODESBELOW

Ethnic group

1=Somali2=Somali Bantu98=Other

Did you everbreastfeed[name]?1=yes2=noGO TO IN1199= don’t knowGO TO IN11

How long afterbirth did you firstput [name] to thebreast?1 = within 1 hr2 = >1hr-<24 hrs3 = ≥24 hrs 99 = don’t know

Was [name]breastfed yesterdayduring the day or atnight?1 = yes2 = no99 = don’t know

1

2

3

4

5

IN11 IN12 IN13 IN14 IN15 IN16 IN17 IN18 IN19 IN20 IN21 IN22 IN23 IN25

ChildNo.

HHNo.

Now I will ask you about what [name] drank or eat during the day and the night. Yesterday, during the day and night,has [name] received (INSERT ITEM HERE)? 1= yes, 2 = no, 99 = don’t know

Did [name] drinkanything from abottle with anipple yesterdayduring the day ornight?

1 = yes2 = no99 = don’t know

Diarrhoea in last 2weeks

1 = yes

2 = noSTOP NOW

99 = don’t knowSTOP NOW

When [name] haddiarrhoea did you feed[name]:

1=less2= the same3=more4=no food

Pla

inw

ate

r

Sugar

wate

r

Fre

sh

fruit

juic

e

Sw

eete

ned

flavoure

dju

ices

(Zeitu

n,A

ltuza,

Mushakil,

vim

to,soda,

afy

a,ta

mu,yahoo,

savannah)

Tea

or

coff

ee

white

or

bla

ck

Infa

ntfo

rmula

:fo

rexam

ple

Mam

ex,

Sahar,

Nan,S

26

Fre

sh

anim

alm

ilkor

any

tinned

or

pow

dere

dm

ilk.

Porr

idge

made

from

CS

B+

or

++

Porr

idge

notm

ade

from

CS

B+

or

++

Medic

ines:fo

rexam

ple

OR

S,

gripe

wate

r

Foods

oth

er

than

liquid

s(s

em

i-solid

and

solid

foods)

1

2

3

4

5CODES:

IN5: 1=July-September 2012, 2=April-June 2012, 3=January-March 2012, 4=October-December 2011, 5=Arrived before October 2011 or born in camps. IN6: 1 = Lower Juba, 2 = MiddleJuba, 3 = Gedo, 4 = Bay, 5 = Bakool, 6 = Lower Shabelle, 7 = Middle Shabelle, 8 = Hiraan, 9 = Mogadishu / Banadir, 98= Other; IN22: For example: pasta, rice, anjera, ugali, potatoes, maize, beans, mango,banana, other fruits and vegetables, meat.


Dadaab Nutrition Survey 2012, Household Listing Form

Date ___ / ___ / 2012 Block |_____|_____|_____|

Camp: 1 = Ifo-2 2=Dagahaley 3=Kambios 4=Ifo 5=Hagadera

Cluster no. |_____|_____| Team number |_____| HH Number |_____|_____|

Please fill in using the following order: HH head, adult males, adult females, children, infants, other relatives

# First Name only M/F Age0-59: age in months

Women: specify if15-49

Weight(kg)

Children6-59m

Height(cm)

Children 6-59m

MUAC(cm)

Children 6-59m

Hb (g/dL)

Non-pregnant womenand children 6-59m only

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17


5. Dadaab Nutrition Survey, September 2012, Kambioos Mortality Questionnaire

Date ___ / ___ / 2012 Block |_____|_____|_____|

Camp: 1 = Ifo-2 2=Dagahaley 3=Kambios 4=Ifo 5=Hagadera

Cluster no. |_____|_____| Team number |_____| HH Number |_____|_____|

Please fill in using the following order: HH head, adult males, adult females, children, infants, other relatives

# First Name only M/F Age0-59: age inmonths

Women:specify if 15-49

Weight(kg)

Children6-59m

Height(cm)

Children 6-59m

MUAC(cm)

Children 6-59m

Hb (g/dL)

Non-pregnantwomen andchildren 6-59monly

Joined/ / left / born /died since June 20th

2012 (World RefugeeDay)CIRCLE IF APPLIES

1 Joined / Born

2 Joined / Born

3 Joined / Born

4 Joined / Born

5 Joined / Born

6 Joined / Born

7 Joined / Born

8 Joined / Born

9 Joined / Born

10 Joined / Born

11 Joined / Born

12 Joined / Born

13 Joined / Born

Listnames

ofpersons

whoLEFT or

DIED

Left / Died

Left / Died

Left / Died

Left / Died


Cluster Control Sheet – Ifo-2 and Hagadera

Cluster Control Sheet – Dadaab Nutrition Survey 2012

Camp: Cluster Number: Date: Team:

HouseholdQuestionnaires

1 2 3 4 5 6 7 8 9 10 11 12

Children 6-59months

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Women15 - 49

1 2 3 4 5 6 7 8 9 10

Infants0-5 months

1 2 3 4

Cluster Control Sheet – Kambioos

Cluster Control Sheet for Kambioos – Dadaab Nutrition Survey 2012

Camp:

KAMBIOOS (Code 3)Cluster Number: Date: Team:

HouseholdQuestionnaire

1 2 3 4 5 6 7 8 9 10 11 12

Children6-59 months

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20

Women15 - 49

1 2 3 4 5 6 7 8 9 10

Infants0-5 months

1 2 3 4

MortalityQuestionnaire

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15


Appendix 8 - Local events calendar: Children 0 - 59 months of ageSeasons Religious

HolidaysLocal Event (in camp of surroundingvillages)

Arabic Calendar SomaliCalendar

Month / year Age(m)

HeightRange

Mid of Xagaa Ramadanended

Fire in Dagahaley market & Fire in Ifo marketArrival of GSUWorld breastfeeding week

Bisha Sideedaad Soon /Ramadhan

August 2012 1

Beginning of Xagaa Ramadanbegan

Explosion in Dagahaley CARE area.Start of July – abduction of 4 NRC staff

Bisha Todobaad Shaba'an July 2012 2

<65cm

End of Gu' World Refugee Day – 20th

JuneIED explosion in Dagahaley

Bisha Luulyo Rajab June 2012 3

Mid of Gu' Bombing of Chairlady in IfoVit A & deworming campaign(malezi bora)Explosion 15

thMay at Naseria market

Bisha Shanaad Jamadul akhir May 2012 4

Beginning of Gu' Mosquito nets being distributed Abriil Jamadul awal April 2012 5

End of Jiilal Start of GFD distribution by NRC Ifo 2 Maarso Malmadone March 2012 665-70

cmMid of Jiilal KRCS began SFP in Ifo2

Bomb-blast in Ifo (IED)Febrayo Mowlid February 2012 7

Beginning of Jililal Closure of MSF Health post 8 in DagahaleyStart of wet-feeding program Ifo2 (by Turkey)

Janaayo Safar January 2012 8

71-76cm

End of Deyr Killing of Security Chairman in HagaderaIMC took over from IRC in Kambioos

Bisha diseenbar Zako December 2011 9

Mid of Deyr Opening of tented hospital in Ifo 2 West Bisha kow iyo Tobnad Arafa November 2011 10

Beginning of Deyr KRCS began operating.Abduction of MSF-Spain staff

Bisha Tobnad Sidital October 2011 11

End of Xagaa End ofRamadan

Kambioos openedRelocation of Dagahaley to Ifo 2

Bisha Sagaalad Soon fur September 2011 12

Mid of Xagaa Start ofRamadan

Strike (MSF staff), outbreak of measles in Ifo2 Bisha Sideedaad Soon /Ramadhan

August 2011 13

77-80cm

Beginning of Xagaa Fight between police and Dagahaley camp Bisha Todobaad Shaba'an July 2011 14End of Gu' Refugee Day / Reception centre opened /

Moon eclipseBusiness men killed in Hagadera

Bisha Luuly Rajab June 2011 15

Mid of Gu' IRC religious strike in Hagadera Bisha Shanaad Jamadul akhir May 2011 16Beginning of Gu' Abriil Jamadul awal April 2011 17End of Jiilal Health post 8 opened in outskirts (cluster 2) Maarso Malmadone March 2011 18Mid of Jiilal Febrayo Mowlid February 2011 19Beginning of Jililal Janaayo Safar January 2011 20

81-86cm

End of Deyr Bisha diseenbar Zako December 2010 21Mid of Deyr Bisha kow iyo Tobnad Arafa November 2010 22Beginning of Deyr Bisha Tob Sigalal October 2010 23End of Xagaa End Ramadan

(09/09/2010)Bisha Sagaalad Soon fur September 2010 24

Mid of Xagaa BeginningRamadan

Bisha Sideedaad Soon/Ramadhan

August 2010 25

Beginning of Xagaa Sudan Somali flight Bisha Todobaad Shaba'an July 2010 26

87-90cm

End of Gu' Refugee Day Bisha Luuly Rajab June 2010 27Mid of Gu' Bisha Shanaad Jamadul akhir May 2010 28Beginning ogf Gu' Conflict between polic and Dagahaley Abriil Jamadul awal April 2010 29End of Jiilal Maarso Malmadone March 2010 30Mid of Jiilal IRC strike. Qarax Madoio Febrayo Mowlid February 2010 31Beginning of Jililal Banamnar Shakhoolo IRC/GTZ Janaayo Safar January 2010 32End of Deyr Bisha diseenbar Zako December 2009 33Mid of Deyr Bisha kow iyo Tobnad Arafa November 2009 34Beginning of Deyr Mental health day Bisha Tob Sigalal October 2009 35End of Xagaa End Ramadan Ciidul fidri. Ciid alfidri

Dagahaley health post 6 burnt downBisha Sagaalad Soon fur September 2009 36


MSF begin operations in Dagahaley Bisha Sideedaad Soon/Ramadhan

August 2009 37

Beginning of Xagaa Bisha Todobaad Shaba'an July 2009 38

91-99cm

End of Gu' Refugee day Bisha Luuly Rajab June 2009 39Mid of Gu' Tirakobka Hagadera Bisha Shanaad Jamadul akhir May 2009 40Beginning ogf Gu' Madobadki Bisha moon eclipse Abriil Jamadul awal April 2009 41End of Jiilal Maarso Malmadone March 2009 42Mid of Jiilal Febrayo Mowlid February 2009 43Beginning of Jililal IRC arrival Janaayo Safar January 2009 44End of Deyr MSF arrival Bisha diseenbar Zako December 2008 45Mid of Deyr Dorasho Election gudamiyal Bisha kow iyo Tobnad Arafa November 2008 46Beginning of Deyr Bisha Tob Sigalal October 2008 47End of Xagaa End Ramadan

(30/09/08)Daadki Biyana Floods Bisha Sagaalad Soon fur September 2008 48


Bisha Sideedaad Soon/Ramadhan

August 2008 49

Beginning of Xagaa Bisha Todobaad Shaba'an July 2008 50

100 –110cm

End of Gu' Refugee day Bisha Luuly Rajab June 2008 51Mid of Gu' Bisha Shanaad Jamadul akhir May 2008 52Beginning ogf Gu' Abriil Jamadul awal April 2008 53End of Jiilal Dabki Firebann block 131 Maarso Malmadone March 2008 54Mid of Jiilal Febrayo Mowlid February 2008 55Beginning of Jililal Janaayo Safar January 2008 56End of Deyr Kenya Dorasho Bisha diseenbar Zako December 2007 57Mid of Deyr Bisha kow iyo Tobnad Arafa November 2007 58Beginning of Deyr End Ramadan Bisha Tob Sigalal October 2007 59End of Xagaa Beginning

Ramadan(12/09/07)

Bisha Sagaalad Soon fur September 2007 60

NUTRITION SURVEYS DADAAB REFUGEE CAMPS Ifo-2, Hagadera ... · UNHCR Dadaab Nutrition Surveys,...

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Transcript of NUTRITION SURVEYS DADAAB REFUGEE CAMPS Ifo-2, Hagadera ... · UNHCR Dadaab Nutrition Surveys,...